Provider Demographics
NPI:1184756363
Name:FUQUA, JEANNE (ND LAC)
Entity type:Individual
Prefix:DR
First Name:JEANNE
Middle Name:
Last Name:FUQUA
Suffix:
Gender:F
Credentials:ND LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-3125
Mailing Address - Country:US
Mailing Address - Phone:860-470-6950
Mailing Address - Fax:203-772-3508
Practice Address - Street 1:111 MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-3125
Practice Address - Country:US
Practice Address - Phone:860-470-6950
Practice Address - Fax:203-772-3508
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT649171100000X
CT000356175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT649OtherACUPUNCTURE LICENSE
171100000XOtherTAXONOMY CODE