Provider Demographics
NPI:1134227101
Name:FITZGERALD, JAMES JR
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:FITZGERALD
Suffix:JR
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JAMES
Other - Middle Name:
Other - Last Name:FITZGERALD
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 563
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98337-0111
Mailing Address - Country:US
Mailing Address - Phone:360-377-9032
Mailing Address - Fax:360-377-0129
Practice Address - Street 1:1007 SCOTT AVE
Practice Address - Street 2:SUITE#F
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-4874
Practice Address - Country:US
Practice Address - Phone:360-377-9032
Practice Address - Fax:360-377-0129
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000046561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA912173743Medicare UPIN
WA11500471Medicare ID - Type UnspecifiedMEDICARE PART B