Healthcare Provider Details

I. General information

NPI: 1972391472
Provider Name (Legal Business Name): JAMELLA FAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2025
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4619 CHESTER AVE APT B210
PHILADELPHIA PA
19143-3683
US

IV. Provider business mailing address

4619 CHESTER AVE APT B210
PHILADELPHIA PA
19143-3683
US

V. Phone/Fax

Practice location:
  • Phone: 267-481-6632
  • Fax:
Mailing address:
  • Phone: 267-481-6632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOC020735
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: