Provider Demographics
NPI:1992534085
Name:FAGAN, ALEXANDRIA (LMSW-CLINICAL)
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
Last Name:FAGAN
Suffix:
Gender:F
Credentials:LMSW-CLINICAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 462
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49204-0462
Mailing Address - Country:US
Mailing Address - Phone:517-201-5790
Mailing Address - Fax:
Practice Address - Street 1:180 W MICHIGAN AVE STE 802
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1300
Practice Address - Country:US
Practice Address - Phone:517-201-5790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-29
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011089651041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical