Provider Demographics
NPI:1275823494
Name:FREDERICK, JAMIE L (MCD, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:L
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 COUNTY ROAD 7290
Mailing Address - Street 2:
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-8121
Mailing Address - Country:US
Mailing Address - Phone:870-270-7963
Mailing Address - Fax:
Practice Address - Street 1:111 MERRIMAN AVE E
Practice Address - Street 2:
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-2941
Practice Address - Country:US
Practice Address - Phone:870-270-7963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-08
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR185789721Medicaid