Provider Demographics
NPI:1902357452
Name:FOGLE, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FOGLE
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 1:706 OGLESBY AVE
Mailing Address - Street 2:SUITE112
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-4616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:706 OGLESBY AVE
Practice Address - Street 2:SUITE112
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-4616
Practice Address - Country:US
Practice Address - Phone:309-585-0241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.012414101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor