Basic Information
| Provider Information | |||||||||
| NPI: | 1629550165 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREDERICK | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1160 E SAINT CLAIR ST | ||||||||
| Address2: | |||||||||
| City: | VINCENNES | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475914853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128853106 | ||||||||
| FaxNumber: | 8128858499 | ||||||||
| Practice Location | |||||||||
| Address1: | 406 N 1ST ST | ||||||||
| Address2: | |||||||||
| City: | VINCENNES | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475911340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128856950 | ||||||||
| FaxNumber: | 8128856951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2018 | ||||||||
| LastUpdateDate: | 09/25/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71008389A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.