Provider Demographics
NPI:1891934980
Name:FORTWENGLER, JESSICA L (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:FORTWENGLER
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:PO BOX 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-489-5730
Mailing Address - Fax:502-489-5733
Practice Address - Street 1:6580 KENWOOD CROSSING ROAD
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014
Practice Address - Country:US
Practice Address - Phone:502-243-3161
Practice Address - Fax:502-243-3164
Is Sole Proprietor?:No
Enumeration Date:2009-02-12
Last Update Date:2015-01-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY42398207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000650401OtherANTHEM
KY50027705OtherPASSPORT
KY7100104670Medicaid
KYP00854282OtherRAILROAD MEDICARE
KY7100104670Medicaid