Healthcare Provider Details

I. General information

NPI: 1184913436
Provider Name (Legal Business Name): JENNIFER ANN FREDERICK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 04/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 BROOK ST #3
WURTSBORO NY
12790-8231
US

IV. Provider business mailing address

PO BOX 634
WURTSBORO NY
12790-0634
US

V. Phone/Fax

Practice location:
  • Phone: 845-644-4160
  • Fax:
Mailing address:
  • Phone: 845-644-4160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number594560
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: