MEDICARE: JALISSA FREDRICK

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	101YM0800X	Mental Health Counselor	7408	TN

General Provider Information

NPI Number	:	1972455327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JALISSA FREDRICK

Provider Business Mailing Address
First Line	:	9295 ACADIA PL
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38018-7151
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9295 ACADIA PL
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38018-7151
Country	:	US
Telephone Number	:	423-508-9964
Fax Number	:

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

Provider Enumeration Date	:	02/10/2026
Last Update Date	:	02/10/2026

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Directions to “ JALISSA FREDRICK ” Practice Location

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