Provider Demographics
NPI:1629386503
Name:FUGATE, JACQUELINE ROSE
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ROSE
Last Name:FUGATE
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 1:117 3RD ST
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-2159
Mailing Address - Country:US
Mailing Address - Phone:606-233-1943
Mailing Address - Fax:
Practice Address - Street 1:117 3RD ST
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-2159
Practice Address - Country:US
Practice Address - Phone:606-233-1943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY000079322222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist