Provider Demographics
NPI:1659001816
Name:FUGATE, JENNIFER (LDO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FUGATE
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 OSBOURNE WAY
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-9636
Mailing Address - Country:US
Mailing Address - Phone:502-867-1224
Mailing Address - Fax:502-867-1226
Practice Address - Street 1:112 OSBOURNE WAY
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9636
Practice Address - Country:US
Practice Address - Phone:502-867-1224
Practice Address - Fax:502-867-1226
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-12
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY110376156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician