Basic Information
| Provider Information | |||||||||
| NPI: | 1205862455 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FITZGERALD | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11745 US HIGHWAY 23 S | ||||||||
| Address2: | |||||||||
| City: | OSSINEKE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497669582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894712156 | ||||||||
| FaxNumber: | 9894715257 | ||||||||
| Practice Location | |||||||||
| Address1: | 11745 US HIGHWAY 23 S | ||||||||
| Address2: | |||||||||
| City: | OSSINEKE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497669582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894712156 | ||||||||
| FaxNumber: | 9894715257 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 5101009215 | MI | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1990638 | 05 | MI | MEDICAID | 2888399 | 05 | MI | MEDICAID |