Provider Demographics
NPI:1417561432
Name:FITZGERALD, JACQUELINE MORGAN
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MORGAN
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:MORGAN
Other - Last Name:WOLFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22 TOMPKINS ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-1458
Mailing Address - Country:US
Mailing Address - Phone:203-419-0381
Mailing Address - Fax:
Practice Address - Street 1:1625 STRAITS TPKE STE 303
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762-1836
Practice Address - Country:US
Practice Address - Phone:203-598-0400
Practice Address - Fax:203-598-0852
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12761225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00490381Medicaid