Provider Demographics
NPI:1891239471
Name:FAGAN, JACQUELYN ALLYSE (RD, CD, CEP)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:ALLYSE
Last Name:FAGAN
Suffix:
Gender:
Credentials:RD, CD, CEP
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:ALLYSE
Other - Last Name:CREWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2202 S CEDAR ST STE 300
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2318
Mailing Address - Country:US
Mailing Address - Phone:253-301-5280
Mailing Address - Fax:
Practice Address - Street 1:2202 S CEDAR ST
Practice Address - Street 2:SUITE 300
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2318
Practice Address - Country:US
Practice Address - Phone:253-301-5280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-15
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI 60713040133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered