Provider Demographics
NPI:1598495384
Name:FITZGERALD, JACKSON RILEY (OD)
Entity Type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:RILEY
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 S HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ELK RIDGE
Mailing Address - State:UT
Mailing Address - Zip Code:84651-8501
Mailing Address - Country:US
Mailing Address - Phone:801-669-3687
Mailing Address - Fax:
Practice Address - Street 1:50 E 4TH AVE
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:WY
Practice Address - Zip Code:83110-5027
Practice Address - Country:US
Practice Address - Phone:307-885-3975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY548T152W00000X
MTOPT-OPT-LIC-4481152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist