Provider Demographics
NPI:1356689608
Name:FAGAN, JENNIFER (RD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FAGAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 ENTERPRISE PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23294-6341
Mailing Address - Country:US
Mailing Address - Phone:804-864-1998
Mailing Address - Fax:804-864-1997
Practice Address - Street 1:2727 ENTERPRISE PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23294-6341
Practice Address - Country:US
Practice Address - Phone:804-864-1998
Practice Address - Fax:804-864-1997
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-22
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered