Provider Demographics
NPI:1306268610
Name:FAYANS, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FAYANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BROOKDALE PLZ
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-3139
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 BROOKDALE PLZ
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-3139
Practice Address - Country:US
Practice Address - Phone:718-240-6281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-07
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0591411223S0112X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist