Provider Demographics
NPI:1568095941
Name:FOGLER, JENNIFER (LMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FOGLER
Suffix:
Gender:F
Credentials:LMT
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 2655
Mailing Address - Street 2:
Mailing Address - City:CAVE JUNCTION
Mailing Address - State:OR
Mailing Address - Zip Code:97523-2655
Mailing Address - Country:US
Mailing Address - Phone:541-415-2024
Mailing Address - Fax:
Practice Address - Street 1:9335 TAKILMA RD
Practice Address - Street 2:
Practice Address - City:CAVE JUNCTION
Practice Address - State:OR
Practice Address - Zip Code:97523-9831
Practice Address - Country:US
Practice Address - Phone:541-415-2024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24203225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR24203OtherLMT#