Provider Demographics
NPI:1255694824
Name:FITZGERALD, JANE POOLE
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:POOLE
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 DEARBORN ST
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10801-4407
Mailing Address - Country:US
Mailing Address - Phone:914-484-7255
Mailing Address - Fax:
Practice Address - Street 1:470 MAMARONECK AVE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-1830
Practice Address - Country:US
Practice Address - Phone:914-421-8270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY399619298174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist