Provider Demographics
NPI:1306516984
Name:FAGERSTROM, JARED MICHAEL (DPT)
Entity type:Individual
Prefix:DR
First Name:JARED
Middle Name:MICHAEL
Last Name:FAGERSTROM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 S GATE PARK
Mailing Address - Street 2:
Mailing Address - City:WEST NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02465-1616
Mailing Address - Country:US
Mailing Address - Phone:952-836-6298
Mailing Address - Fax:
Practice Address - Street 1:940 BELMONT ST BLDG 2
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5568
Practice Address - Country:US
Practice Address - Phone:774-826-1563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA25734225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist