Provider Demographics
NPI:1639615867
Name:FREDRICKSON, JAMES MARK (DPT)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MARK
Last Name:FREDRICKSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18152 PRESTON RD STE I-2
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75252-5427
Mailing Address - Country:US
Mailing Address - Phone:469-200-2832
Mailing Address - Fax:469-269-1074
Practice Address - Street 1:18152 PRESTON RD STE I-2
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252-5427
Practice Address - Country:US
Practice Address - Phone:469-200-2832
Practice Address - Fax:469-269-1074
Is Sole Proprietor?:No
Enumeration Date:2017-01-11
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1345070225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist