Provider Demographics
NPI:1174178461
Name:FAJT, JENNIFER L (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:FAJT
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 N SUMMIT ST FL 7
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-2615
Mailing Address - Country:US
Mailing Address - Phone:419-252-6018
Mailing Address - Fax:800-564-5952
Practice Address - Street 1:1848 GREENTREE RD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15220-1851
Practice Address - Country:US
Practice Address - Phone:800-427-1902
Practice Address - Fax:419-531-2664
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP020592363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily