Provider Demographics
NPI:1073059143
Name:FREDERICK, JARON (MA)
Entity Type:Individual
Prefix:MR
First Name:JARON
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2321 ROAD 116
Mailing Address - Street 2:
Mailing Address - City:FORT LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82212-7634
Mailing Address - Country:US
Mailing Address - Phone:307-837-2050
Mailing Address - Fax:
Practice Address - Street 1:136 W 21ST AVE
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:WY
Practice Address - Zip Code:82240-2721
Practice Address - Country:US
Practice Address - Phone:307-532-2119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-988101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor