Provider Demographics
NPI:1053731018
Name:VALENCIA-FAGOT, JESSICA MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:MARIE
Last Name:VALENCIA-FAGOT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:VALENCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:7509 MENCHACA RD UNIT 109
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-6050
Mailing Address - Country:US
Mailing Address - Phone:512-643-5101
Mailing Address - Fax:833-594-1316
Practice Address - Street 1:7509 MENCHACA RD UNIT 109
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-6050
Practice Address - Country:US
Practice Address - Phone:512-643-5101
Practice Address - Fax:833-594-1316
Is Sole Proprietor?:No
Enumeration Date:2014-04-17
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD4627793390200000X
TX38205103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program