Provider Demographics
NPI:1093743163
Name:FREDERICKS, JENNIFER S (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 S IL ROUTE 59
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-1694
Mailing Address - Country:US
Mailing Address - Phone:630-483-5930
Mailing Address - Fax:630-483-5939
Practice Address - Street 1:820 S IL ROUTE 59
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103-1694
Practice Address - Country:US
Practice Address - Phone:630-483-5930
Practice Address - Fax:630-483-5939
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106524207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3631498336019001OtherCDPG HFS PAYEE ID
IL0222075OtherBLUE CROSS GROUP NUMBER
ID036106524Medicaid
ID36-3149833OtherTAX IDENTIFICATION NUMBER
ID36-3149833OtherTAX IDENTIFICATION NUMBER
IL482450Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
IL080188208Medicare PIN