Provider Demographics
NPI:1497835169
Name:FREDERICK, JENNIFER LEE (CRNA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:GARVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:320 WHITTINGTON PKWY
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4928
Mailing Address - Country:US
Mailing Address - Phone:502-625-5584
Mailing Address - Fax:502-426-2264
Practice Address - Street 1:320 WHITTINGTON PKWY
Practice Address - Street 2:SUITE 301
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4928
Practice Address - Country:US
Practice Address - Phone:502-625-5584
Practice Address - Fax:502-426-2264
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5096A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50016501OtherPASSPORT
KY7100025040Medicaid
KY2867285000OtherPASSPORT ADVANTAGE
IN200873920Medicaid
IN200873920Medicaid
KY7100025040Medicaid