Provider Demographics
NPI:1770912024
Name:FITZGERALD, JESSE MATTHEW
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:MATTHEW
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 NEWHALL ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-1708
Mailing Address - Country:US
Mailing Address - Phone:715-651-7382
Mailing Address - Fax:
Practice Address - Street 1:228 NEWHALL ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-1708
Practice Address - Country:US
Practice Address - Phone:715-651-7382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-07
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1533-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100033830Medicaid