Provider Demographics
NPI:1235190885
Name:FREDERICK, JACKIE (CRNP)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 INDIAN FOREST TRL
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35124-3706
Mailing Address - Country:US
Mailing Address - Phone:205-991-8422
Mailing Address - Fax:205-669-4883
Practice Address - Street 1:201 OLD HIGHWAY 25 E
Practice Address - Street 2:
Practice Address - City:COLUMBIANA
Practice Address - State:AL
Practice Address - Zip Code:35051-9373
Practice Address - Country:US
Practice Address - Phone:205-669-4884
Practice Address - Fax:205-669-4883
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-029953363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000060256Medicaid
AL000060256Medicaid
ALP06534Medicare UPIN