Provider Demographics
NPI:1750332235
Name:FAGEN, JENNIFER JACQUELYN (PT, MSPT, PRPC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JACQUELYN
Last Name:FAGEN
Suffix:
Gender:F
Credentials:PT, MSPT, PRPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 19TH ST S
Mailing Address - Street 2:SRC R385
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35249-7201
Mailing Address - Country:US
Mailing Address - Phone:205-975-4922
Mailing Address - Fax:
Practice Address - Street 1:1717 6TH AVE SOUTH
Practice Address - Street 2:SRC R385
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35249-3329
Practice Address - Country:US
Practice Address - Phone:205-975-4922
Practice Address - Fax:205-934-7420
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH3564225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051528438FAGMedicare ID - Type UnspecifiedINDIVIDUAL