Provider Demographics
NPI:1891501367
Name:FITZGERALD, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5226 S 75 W
Mailing Address - Street 2:
Mailing Address - City:CHALMERS
Mailing Address - State:IN
Mailing Address - Zip Code:47929-8094
Mailing Address - Country:US
Mailing Address - Phone:765-607-0958
Mailing Address - Fax:
Practice Address - Street 1:3218 DAUGHERTY DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47909-3997
Practice Address - Country:US
Practice Address - Phone:765-607-0958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71016397A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily