Provider Demographics
NPI:1811306335
Name:FITZGERALD, JENNIFER (LMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:673 CAMERON DRIVE
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002
Mailing Address - Country:US
Mailing Address - Phone:847-508-7855
Mailing Address - Fax:
Practice Address - Street 1:673 CAMERON DRIVE
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002
Practice Address - Country:US
Practice Address - Phone:847-508-7855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-08
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227-007459225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist