Provider Demographics
NPI:1871848283
Name:FITZGERALD, JENNA R (PHD LPC)
Entity Type:Individual
Prefix:DR
First Name:JENNA
Middle Name:R
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:PHD LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3959 ELECTRIC RD STE 425
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-4563
Mailing Address - Country:US
Mailing Address - Phone:540-524-0359
Mailing Address - Fax:
Practice Address - Street 1:3959 ELECTRIC RD STE 425
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-4563
Practice Address - Country:US
Practice Address - Phone:540-206-2385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701007605101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30604011Medicaid