Provider Demographics
NPI:1588273619
Name:FABIAN, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FABIAN
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 1:5441 E 400 S
Mailing Address - Street 2:
Mailing Address - City:LAOTTO
Mailing Address - State:IN
Mailing Address - Zip Code:46763-9724
Mailing Address - Country:US
Mailing Address - Phone:260-452-4020
Mailing Address - Fax:
Practice Address - Street 1:6131 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-4905
Practice Address - Country:US
Practice Address - Phone:260-459-6040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-20-43370103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst