Provider Demographics
NPI:1649015553
Name:FITZGERALD, JENNA
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 SAINT LOUIS AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-1521
Mailing Address - Country:US
Mailing Address - Phone:701-870-0734
Mailing Address - Fax:
Practice Address - Street 1:206 SAINT LOUIS AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-1521
Practice Address - Country:US
Practice Address - Phone:701-870-0734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL171M00000X, 374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No171M00000XOther Service ProvidersCase Manager/Care Coordinator