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General NPI Number Information
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NPI Number | 1528549508
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Entity Type | Individual
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Provider Name | JESSICA FAGEN PSYD
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Gender | Female
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Dates
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Enumeration Date | 08/27/2018
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Last Update Date | 10/20/2021
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Provider Practice Location Address
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Address Line | 141 E 55TH ST APT 3D
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City | NEW YORK
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State | NY
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Zip | 10022-4050
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Country | US
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Telephone | 516-728-5246
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Fax |
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Provider Business Mailing Address
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Address Line | 28 HOYTS LN
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City | BEDFORD CORNERS
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State | NY
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Zip | 10549-4856
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Country | US
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Telephone | 516-728-5246
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 022717
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License Number State | NY
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