Provider Demographics
NPI:1134807464
Name:FUDGE, JENNIFFER ANNETTE
Entity type:Individual
Prefix:MRS
First Name:JENNIFFER
Middle Name:ANNETTE
Last Name:FUDGE
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 1:135 LONGHUNTERS TRL
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-1267
Mailing Address - Country:US
Mailing Address - Phone:270-670-8326
Mailing Address - Fax:
Practice Address - Street 1:135 LONGHUNTERS TRL
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-1267
Practice Address - Country:US
Practice Address - Phone:270-670-8326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist