MEDICARE: DR. JACOB KELLEY FREDERICK DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2025017762	MO

General Provider Information

NPI Number	:	1124811393
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACOB KELLEY FREDERICK DPT

Provider Business Mailing Address
First Line	:	3513 BROOKSIDE CROSSING DR
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63301-4901
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3074 WINGHAVEN BLVD
Second Line	:
City	:	O FALLON
State	:	MO
Zip	:	63368-3620
Country	:	US
Telephone Number	:	636-265-4100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2025
Last Update Date	:	05/28/2025

Similar Medicare Providers

1942088554 — AUSTIN BUCHER
Practice Location Address:

3074 WINGHAVEN BLVD
O FALLON, MO
63368-3620

Practice Phone: 636-265-4100
Practice Fax:

1174195861 — KALEY MAAG
Practice Location Address:

3074 WINGHAVEN BLVD
O FALLON, MO
63368-3620

Practice Phone: 636-265-4100
Practice Fax:

1124413711 — POWERBACK REHABILITATION LLC
Practice Location Address:

3620 LITTLEDALE RD , C/O KENSINGTON PARK
KENSINGTON, MD
20895-3424

Practice Phone: 301-946-7700
Practice Fax:

1003952458 — ELDAD SHAUL BIALECKI M.D.
Practice Location Address:

20 PROGRESS POINT PKWY STE 206
O FALLON, MO
63368-2207

Practice Phone: 636-344-1073
Practice Fax: 636-344-1075

1417732033 — MRS. KEATON ELAINE COLEMAN LCSW
Practice Location Address:

4663 HIGHWAY K
O FALLON, MO
63368-8690

Practice Phone: 636-538-8619
Practice Fax:

1952137861 — PROACTIVE BEHAVIORAL HEALTH SOLUTIONS, INC.
Practice Location Address:

856 WATERBURY FALLS DR STE 102
O FALLON, MO
63368-2219

Practice Phone: 636-339-1190
Practice Fax: 816-631-0171

Directions to “ DR. JACOB KELLEY FREDERICK DPT” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.