Healthcare Provider Details

I. General information

NPI: 1366821431
Provider Name (Legal Business Name): JAYNE ANN FREDRICK LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2015
Last Update Date: 12/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CAMPUS DR
HANCOCK MI
49930-1452
US

IV. Provider business mailing address

506 CAMPUS DR
HANCOCK MI
49930-1569
US

V. Phone/Fax

Practice location:
  • Phone: 906-483-1060
  • Fax: 906-483-1270
Mailing address:
  • Phone: 906-483-1060
  • Fax: 906-483-1270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801096884
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: