Provider Demographics
NPI:1174388367
Name:FAGERLIE, JAMIE ANN
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:ANN
Last Name:FAGERLIE
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 1:226 WHITEBIRCH DR
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48629-9100
Mailing Address - Country:US
Mailing Address - Phone:989-390-5082
Mailing Address - Fax:
Practice Address - Street 1:9249 W LAKE CITY RD
Practice Address - Street 2:
Practice Address - City:HOUGHTON LAKE
Practice Address - State:MI
Practice Address - Zip Code:48629-9602
Practice Address - Country:US
Practice Address - Phone:198-939-0508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-16
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker