Provider Demographics
NPI:1407824394
Name:FREDRICK, JACQUELINE JIANG (OD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:JIANG
Last Name:FREDRICK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5511 MERCHANTS VIEW SQ
Mailing Address - Street 2:
Mailing Address - City:HAYMARKET
Mailing Address - State:VA
Mailing Address - Zip Code:20169-5439
Mailing Address - Country:US
Mailing Address - Phone:703-659-4430
Mailing Address - Fax:703-273-0239
Practice Address - Street 1:5511 MERCHANTS VIEW SQ
Practice Address - Street 2:
Practice Address - City:HAYMARKET
Practice Address - State:VA
Practice Address - Zip Code:20169-5439
Practice Address - Country:US
Practice Address - Phone:703-659-4430
Practice Address - Fax:703-659-4438
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001433152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010129460Medicaid
VA018520D66Medicare ID - Type Unspecified