Provider Demographics
NPI:1144428855
Name:FRY, JEFFREY PATRICK (PHD, NCSP)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:PATRICK
Last Name:FRY
Suffix:
Gender:M
Credentials:PHD, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6713
Mailing Address - Country:US
Mailing Address - Phone:541-690-2906
Mailing Address - Fax:458-226-2667
Practice Address - Street 1:809 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6713
Practice Address - Country:US
Practice Address - Phone:541-690-2906
Practice Address - Fax:458-226-2667
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3208103T00000X
FLSS 903103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist