Healthcare Provider Details

I. General information

NPI: 1346752557
Provider Name (Legal Business Name): JENNIFER K FOGLE APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2017
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 E US ROUTE 36
DECATUR IL
62521-5003
US

IV. Provider business mailing address

PO BOX 3428
SPRINGFIELD IL
62708-3428
US

V. Phone/Fax

Practice location:
  • Phone: 217-876-5320
  • Fax: 217-876-5865
Mailing address:
  • Phone: 217-876-5320
  • Fax: 217-876-5865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209016606
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: