Provider Demographics
NPI:1346752557
Name:FOGLE, JENNIFER K (APN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:FOGLE
Suffix:
Gender:F
Credentials:APN
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 3428
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62708-3428
Mailing Address - Country:US
Mailing Address - Phone:217-876-5320
Mailing Address - Fax:217-876-5865
Practice Address - Street 1:4455 E US ROUTE 36
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-5003
Practice Address - Country:US
Practice Address - Phone:217-876-5320
Practice Address - Fax:217-876-5865
Is Sole Proprietor?:No
Enumeration Date:2017-10-27
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016606363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209016606OtherAPN LICENSE