MEDICARE: JON FREDERICKSON MSW

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	1041C0700X	Clinical Social Worker	LC301869	DC

General Provider Information

NPI Number	:	1598796849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JON FREDERICKSON MSW

Provider Business Mailing Address
First Line	:	1844 47TH PL NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20007-1909
Country	:	US
Telephone Number	:	202-986-4575
Fax Number	:	202-333-3217

Provider Business Practice Location Address
First Line	:	3000 CONNECTICUT AVE NW
Second Line	:	SUITE 400
City	:	WASHINGTON
State	:	DC
Zip	:	20008-2509
Country	:	US
Telephone Number	:	202-986-4575
Fax Number	:	202-333-3217

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

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	07/08/2007

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