Provider Demographics
NPI:1447220603
Name:FITZGERALD, JAY JOSEPH (DC)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:JOSEPH
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 1ST. ST. SW
Mailing Address - Street 2:PO BOX 758
Mailing Address - City:WAGNER
Mailing Address - State:SD
Mailing Address - Zip Code:57380
Mailing Address - Country:US
Mailing Address - Phone:605-384-5419
Mailing Address - Fax:605-384-5410
Practice Address - Street 1:109 1ST. ST. SW
Practice Address - Street 2:
Practice Address - City:WAGNER
Practice Address - State:SD
Practice Address - Zip Code:57380
Practice Address - Country:US
Practice Address - Phone:605-384-5419
Practice Address - Fax:605-384-5410
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD840111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7604080Medicaid
SD41229Medicare ID - Type Unspecified
SD7604080Medicaid