Provider Demographics
NPI:1700492329
Name:FOVARGUE, JENIFFER LYNN
Entity Type:Individual
Prefix:MRS
First Name:JENIFFER
Middle Name:LYNN
Last Name:FOVARGUE
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 1:10626 TIBBETTS RD
Mailing Address - Street 2:
Mailing Address - City:KIRTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44094-5196
Mailing Address - Country:US
Mailing Address - Phone:440-867-5812
Mailing Address - Fax:
Practice Address - Street 1:10626 TIBBETTS RD
Practice Address - Street 2:
Practice Address - City:KIRTLAND
Practice Address - State:OH
Practice Address - Zip Code:44094-5196
Practice Address - Country:US
Practice Address - Phone:440-867-5812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4303829171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor