Healthcare Provider Details

I. General information

NPI: 1871924407
Provider Name (Legal Business Name): JENNIFER FAGAN MA 60367097
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2013
Last Update Date: 12/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 BICKFORD AVE STE 201
SNOHOMISH WA
98290-1771
US

IV. Provider business mailing address

1800 BICKFORD AVE STE 201
SNOHOMISH WA
98290-1771
US

V. Phone/Fax

Practice location:
  • Phone: 425-319-1123
  • Fax: 360-863-2649
Mailing address:
  • Phone: 425-319-1123
  • Fax: 360-863-2649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 60367097
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: