Provider Demographics
NPI:1235771098
Name:FREDRICKS, SARAH JAYNE
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:JAYNE
Last Name:FREDRICKS
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 1:8977 HOMERICH AVE SW
Mailing Address - Street 2:
Mailing Address - City:BYRON CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49315-8627
Mailing Address - Country:US
Mailing Address - Phone:616-610-7704
Mailing Address - Fax:
Practice Address - Street 1:300 S STATE ST STE 13
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-1678
Practice Address - Country:US
Practice Address - Phone:616-772-1733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-14
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801105473104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker