Basic Information
| Provider Information | |||||||||
| NPI: | 1194890590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRITCH | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 428 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 830010428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077398999 | ||||||||
| FaxNumber: | 3077394811 | ||||||||
| Practice Location | |||||||||
| Address1: | 1415 S HWY 89 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 830018515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077398999 | ||||||||
| FaxNumber: | 3077394811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 02/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 292 | WY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 292 | WY | N | Allopathic & Osteopathic Physicians | Family Medicine | 363A00000X | 292 | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 125792700 | 05 | WY | MEDICAID |