Provider Demographics
NPI:1720749237
Name:FOGARTY, JAIME N (LSW)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:N
Last Name:FOGARTY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 293
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-0293
Mailing Address - Country:US
Mailing Address - Phone:567-343-6068
Mailing Address - Fax:413-254-6065
Practice Address - Street 1:850 W ELM ST
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1189
Practice Address - Country:US
Practice Address - Phone:567-343-6068
Practice Address - Fax:413-254-6065
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical