Provider Demographics
NPI:1275818940
Name:FOGG-JENKINS, CONNIE JEAN
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:JEAN
Last Name:FOGG-JENKINS
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 1:12290 S PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:ALSIP
Mailing Address - State:IL
Mailing Address - Zip Code:60803-1405
Mailing Address - Country:US
Mailing Address - Phone:708-385-2006
Mailing Address - Fax:708-385-3124
Practice Address - Street 1:12290 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:ALSIP
Practice Address - State:IL
Practice Address - Zip Code:60803-1405
Practice Address - Country:US
Practice Address - Phone:708-385-2006
Practice Address - Fax:708-385-3124
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051036254183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist