Basic Information
| Provider Information | |||||||||
| NPI: | 1205263480 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FUGATE | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | LPCC-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 380 SUWANNEE TRAIL ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421037956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709015000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 135 OLIVER ST | ||||||||
| Address2: | |||||||||
| City: | SCOTTSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421648801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707917003 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2013 | ||||||||
| LastUpdateDate: | 05/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 168886 | KY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 7100437560 | 05 | KY | MEDICAID |