Healthcare Provider Details

I. General information

NPI: 1518201235
Provider Name (Legal Business Name): JILL ALLISON FAGEN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2012
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 GLENWICK PL
ALLEN TX
75013-1528
US

IV. Provider business mailing address

201 GLENWICK PL
ALLEN TX
75013-1528
US

V. Phone/Fax

Practice location:
  • Phone: 972-489-9260
  • Fax:
Mailing address:
  • Phone: 972-489-9260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2037240
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: