Provider Demographics
NPI:1013640762
Name:FOGLE, JENNIFER ANN (MA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:FOGLE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 EMERSON AVE
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26104
Mailing Address - Country:US
Mailing Address - Phone:304-622-7511
Mailing Address - Fax:304-622-6856
Practice Address - Street 1:2910 EMERSON AVE
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26104
Practice Address - Country:US
Practice Address - Phone:304-239-5355
Practice Address - Fax:304-622-6856
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1619379559Medicaid