Provider Demographics
NPI:1215581418
Name:FREDINE, JESSICA MB
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MB
Last Name:FREDINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 COTTONTAIL LN
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-5125
Mailing Address - Country:US
Mailing Address - Phone:732-529-7120
Mailing Address - Fax:
Practice Address - Street 1:7300 METRO BLVD
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2303
Practice Address - Country:US
Practice Address - Phone:952-887-1688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2862237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist