Provider Demographics
NPI:1972391472
Name:FAGAN, JAMELLA
Entity type:Individual
Prefix:
First Name:JAMELLA
Middle Name:
Last Name:FAGAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4619 CHESTER AVE APT B210
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-3683
Mailing Address - Country:US
Mailing Address - Phone:267-481-6632
Mailing Address - Fax:
Practice Address - Street 1:4619 CHESTER AVE APT B210
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-3683
Practice Address - Country:US
Practice Address - Phone:267-481-6632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-25
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC020735225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist