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General NPI Number Information
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NPI Number | 1952597767
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Entity Type | Organization
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Legal Business Name | JAYNE FABRY, PTC ASSOCIATES
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Dates
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Enumeration Date | 09/15/2007
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Last Update Date | 08/12/2008
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Provider Practice Location Address
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Address Line | 1651 W CENTRE AVE
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City | PORTAGE
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State | MI
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Zip | 49024-6312
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Country | US
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Telephone | 269-552-9832
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Fax |
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Provider Business Mailing Address
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Address Line | 1651 W CENTRE AVE
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City | PORTAGE
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State | MI
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Zip | 49024-6312
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Country | US
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Telephone | 269-552-9832
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JAYNE FABRY
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Credential | CLINICAL PSYCHOLOGIS
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Telephone | 269-552-9832
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 6301008864
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License Number State | MI
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