Healthcare Provider Details

I. General information

NPI: 1609092543
Provider Name (Legal Business Name): JONNETTA J FOGERTY MM, MT-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1562 W EDINBURGH BND
BLOOMINGTON IN
47403-8950
US

IV. Provider business mailing address

1562 W EDINBURGH BND
BLOOMINGTON IN
47403-8950
US

V. Phone/Fax

Practice location:
  • Phone: 812-339-5589
  • Fax:
Mailing address:
  • Phone: 812-339-5589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: