Provider Demographics
NPI:1568528248
Name:FREDERICK, JACQUELINE (MS RD)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:MS RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 ELM ST
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-5816
Mailing Address - Country:US
Mailing Address - Phone:973-731-4971
Mailing Address - Fax:
Practice Address - Street 1:117 ELM ST
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-5816
Practice Address - Country:US
Practice Address - Phone:973-731-4971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ057190Medicare ID - Type Unspecified
NJP57249Medicare UPIN