Provider Demographics
NPI:1558756205
Name:FITZPATRICK, JACKLYN M (GNP-C)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:M
Last Name:FITZPATRICK
Suffix:
Gender:F
Credentials:GNP-C
Other - Prefix:
Other - First Name:JACKLYN
Other - Middle Name:M
Other - Last Name:HEDGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-1624
Mailing Address - Fax:618-724-4628
Practice Address - Street 1:4241 STATE HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:CHRISTOPHER
Practice Address - State:IL
Practice Address - Zip Code:62822-1037
Practice Address - Country:US
Practice Address - Phone:618-724-2401
Practice Address - Fax:618-724-2571
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.012480363LF0000X, 363LP2300X
IL209012480363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care