Healthcare Provider Details

I. General information

NPI: 1316699705
Provider Name (Legal Business Name): KATHRYN JEAN FAGAN DC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2022
Last Update Date: 01/26/2022
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 W 4TH ST STE B
JUSTIN TX
76247-5014
US

IV. Provider business mailing address

112 W 4TH ST STE B
JUSTIN TX
76247-5014
US

V. Phone/Fax

Practice location:
  • Phone: 940-648-1700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number15048
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: