Provider Demographics
NPI:1467507509
Name:FREDRICKSON, JANN R (MA LICSW)
Entity Type:Individual
Prefix:MS
First Name:JANN
Middle Name:R
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:MA LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 21ST ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:NEWPORT
Mailing Address - State:MN
Mailing Address - Zip Code:55055-1094
Mailing Address - Country:US
Mailing Address - Phone:651-208-6458
Mailing Address - Fax:
Practice Address - Street 1:303 21ST ST
Practice Address - Street 2:SUITE 209
Practice Address - City:NEWPORT
Practice Address - State:MN
Practice Address - Zip Code:55055-1094
Practice Address - Country:US
Practice Address - Phone:651-208-6458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN08938101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN08938OtherSTATE LICENSURE