Basic Information
| Provider Information | |||||||||
| NPI: | 1891934980 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORTWENGLER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 950248 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024895730 | ||||||||
| FaxNumber: | 5024895733 | ||||||||
| Practice Location | |||||||||
| Address1: | 6580 KENWOOD CROSSING ROAD | ||||||||
| Address2: | |||||||||
| City: | CRESTWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022433161 | ||||||||
| FaxNumber: | 5022433164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2009 | ||||||||
| LastUpdateDate: | 01/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 42398 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000650401 | 01 | KY | ANTHEM | OTHER | 50027705 | 01 | KY | PASSPORT | OTHER | 7100104670 | 05 | KY | MEDICAID | P00854282 | 01 | KY | RAILROAD MEDICARE | OTHER |