MEDICARE: DR. JESSICA FAGEN PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	022717	NY

General Provider Information

NPI Number	:	1528549508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSICA FAGEN PSYD

Provider Business Mailing Address
First Line	:	28 HOYTS LN
Second Line	:
City	:	BEDFORD CORNERS
State	:	NY
Zip	:	10549-4856
Country	:	US
Telephone Number	:	516-728-5246
Fax Number	:

Provider Business Practice Location Address
First Line	:	141 E 55TH ST APT 3D
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10022-4050
Country	:	US
Telephone Number	:	516-728-5246
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/27/2018
Last Update Date	:	10/20/2021

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