Provider Demographics
NPI:1528549508
Name:FAGEN, JESSICA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:FAGEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 HOYTS LN
Mailing Address - Street 2:
Mailing Address - City:BEDFORD CORNERS
Mailing Address - State:NY
Mailing Address - Zip Code:10549-4856
Mailing Address - Country:US
Mailing Address - Phone:516-728-5246
Mailing Address - Fax:
Practice Address - Street 1:141 E 55TH ST APT 3D
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-4050
Practice Address - Country:US
Practice Address - Phone:516-728-5246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022717103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical