Provider Demographics
NPI:1376019794
Name:FITZGIBBONS, JEAN MARY
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:MARY
Last Name:FITZGIBBONS
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 1:1217 PRESERVATION WAY UNIT 102
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405-4356
Mailing Address - Country:US
Mailing Address - Phone:201-709-0258
Mailing Address - Fax:
Practice Address - Street 1:4130 OLEANDER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6843
Practice Address - Country:US
Practice Address - Phone:910-679-8385
Practice Address - Fax:910-679-8387
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13217235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty