Provider Demographics
NPI:1437342839
Name:FEDDOCK, JAMIE ROSE (MA)
Entity Type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:ROSE
Last Name:FEDDOCK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 12TH AVE S APT 1
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-4144
Mailing Address - Country:US
Mailing Address - Phone:480-650-0792
Mailing Address - Fax:
Practice Address - Street 1:1745 12TH AVE S APT 1
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-4144
Practice Address - Country:US
Practice Address - Phone:480-650-0792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2010-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-06-3182103TM1800X
1-06-3182103K00000X
WACL60166749101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No101Y00000XBehavioral Health & Social Service ProvidersCounselor