Provider Demographics
NPI:1518490499
Name:FUQUA, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:FUQUA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 CAMPUS PL
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2308
Mailing Address - Country:US
Mailing Address - Phone:502-253-5924
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:4003 KRESGE WAY STE 500
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-5603
Practice Address - Country:US
Practice Address - Phone:502-897-1166
Practice Address - Fax:502-928-2988
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV29128207R00000X
WV390200000X
KY60622207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7101057390Medicaid