Provider Demographics
NPI:1417267808
Name:FREDRICKSON, JUDY CAMPBELL (LMP)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:CAMPBELL
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427582 SR 20
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:WA
Mailing Address - Zip Code:99156-9787
Mailing Address - Country:US
Mailing Address - Phone:509-671-7035
Mailing Address - Fax:
Practice Address - Street 1:812 FIRST ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:WA
Practice Address - Zip Code:99156-9787
Practice Address - Country:US
Practice Address - Phone:509-671-7035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60177974225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist