MEDICARE: JAMELLA FAGAN

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	225X00000X	Occupational Therapist	OC020735	PA

General Provider Information

NPI Number	:	1972391472
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMELLA FAGAN

Provider Business Mailing Address
First Line	:	4619 CHESTER AVE APT B210
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19143-3683
Country	:	US
Telephone Number	:	267-481-6632
Fax Number	:

Provider Business Practice Location Address
First Line	:	4619 CHESTER AVE APT B210
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19143-3683
Country	:	US
Telephone Number	:	267-481-6632
Fax Number	:

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

Provider Enumeration Date	:	04/25/2025
Last Update Date	:	04/25/2025

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Directions to “ JAMELLA FAGAN ” Practice Location

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