Provider Demographics
NPI:1174179121
Name:FAGAN, JENNIFER JANE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JANE
Last Name:FAGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:JANE
Other - Last Name:TOMFORDE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6 FREMONT RD
Mailing Address - Street 2:
Mailing Address - City:WEST SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11796-1009
Mailing Address - Country:US
Mailing Address - Phone:631-678-1355
Mailing Address - Fax:
Practice Address - Street 1:6 FREMONT RD
Practice Address - Street 2:
Practice Address - City:WEST SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11796-1009
Practice Address - Country:US
Practice Address - Phone:631-678-1355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist