Provider Demographics
NPI:1316699705
Name:FAGAN, KATHRYN JEAN (DC)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:JEAN
Last Name:FAGAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 W 4TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:JUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:76247-5014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 W 4TH ST STE B
Practice Address - Street 2:
Practice Address - City:JUSTIN
Practice Address - State:TX
Practice Address - Zip Code:76247-5014
Practice Address - Country:US
Practice Address - Phone:940-648-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15048111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor