Healthcare Provider Details

I. General information

NPI: 1295078152
Provider Name (Legal Business Name): JESSICA ELIZABETH FOGARTY JAMES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2013
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3223 N BROAD ST
PHILADELPHIA PA
19140-5007
US

IV. Provider business mailing address

2450 W HUNTING PARK AVE
PHILADELPHIA PA
19129-1302
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-5437
  • Fax: 215-707-5180
Mailing address:
  • Phone: 215-707-5437
  • Fax: 215-707-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD458361
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: