Provider Demographics
NPI:1609092543
Name:FOGERTY, JONNETTA J (MM, MT-BC)
Entity Type:Individual
Prefix:
First Name:JONNETTA
Middle Name:J
Last Name:FOGERTY
Suffix:
Gender:F
Credentials:MM, MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1562 W EDINBURGH BND
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-8950
Mailing Address - Country:US
Mailing Address - Phone:812-339-5589
Mailing Address - Fax:
Practice Address - Street 1:1562 W EDINBURGH BND
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-8950
Practice Address - Country:US
Practice Address - Phone:812-339-5589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist