Provider Demographics
NPI:1639391006
Name:FREY, JAMIE LYNN (MD)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:FREY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-691-2903
Mailing Address - Fax:309-691-2909
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-691-2903
Practice Address - Fax:309-691-2909
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036124992207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036124992Medicaid