Provider Demographics
NPI:1447619234
Name:FITZGERALD, JESSICA SARAHMARIE (SUDP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SARAHMARIE
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2429
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8486
Mailing Address - Country:US
Mailing Address - Phone:360-353-9494
Mailing Address - Fax:360-353-9440
Practice Address - Street 1:900 FIR ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2544
Practice Address - Country:US
Practice Address - Phone:360-575-3316
Practice Address - Fax:360-353-9440
Is Sole Proprietor?:No
Enumeration Date:2016-02-22
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60458200101YA0400X
WACP60636603101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)