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NPI Code Detail

MEDICARE: MRS. JADE ELISE FAGAN PT

MEDICARE: MRS. JADE ELISE FAGAN PT
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
12251G0304XGeriatric Physical Therapist1158980TX

General Provider Information

NPI Number : 1881989606
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. JADE ELISE FAGAN PT
Provider Business Mailing Address
First Line : 2936 ESTERBROOK DR
Second Line :
City : FARMERS BRANCH
State : TX
Zip : 75234-4937
Country : US
Telephone Number : 217-405-6853
Fax Number :
Provider Business Practice Location Address
First Line : 3362 FOREST LN
Second Line :
City : DALLAS
State : TX
Zip : 75234-7796
Country : US
Telephone Number : 972-488-1300
Fax Number : 972-488-1301
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/09/2011
Last Update Date : 06/09/2011

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