Provider Demographics
NPI:1811482516
Name:FATICA, JACK PASQUALE (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:PASQUALE
Last Name:FATICA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:671 HOES LN W
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-8021
Mailing Address - Country:US
Mailing Address - Phone:732-235-5500
Mailing Address - Fax:
Practice Address - Street 1:671 HOES LN W
Practice Address - Street 2:
Practice Address - City:PISCATAWAY
Practice Address - State:NJ
Practice Address - Zip Code:08854-8021
Practice Address - Country:US
Practice Address - Phone:732-235-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA112571002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry