Provider Demographics
NPI:1730242108
Name:FOUQUETTE, JENNIFER LYNN (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:FOUQUETTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:489 FORT JOHNSON RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-9114
Mailing Address - Country:US
Mailing Address - Phone:843-469-2973
Mailing Address - Fax:
Practice Address - Street 1:2117 GERVAIS ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-1805
Practice Address - Country:US
Practice Address - Phone:803-744-0540
Practice Address - Fax:803-744-0542
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC31446207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC314467Medicaid