Provider Demographics
NPI:1952597767
Name:JAYNE FABRY, PTC ASSOCIATES
Entity Type:Organization
Organization Name:JAYNE FABRY, PTC ASSOCIATES
Other - Org Name:PROFESSIONAL THERAPY CONSULTATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:FABRY
Authorized Official - Suffix:
Authorized Official - Credentials:CLINICAL PSYCHOLOGIS
Authorized Official - Phone:269-552-9832
Mailing Address - Street 1:1651 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-6312
Mailing Address - Country:US
Mailing Address - Phone:269-552-9832
Mailing Address - Fax:
Practice Address - Street 1:1651 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-6312
Practice Address - Country:US
Practice Address - Phone:269-552-9832
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-15
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008864103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C913440OtherBCBSM