Provider Demographics
NPI:1659049344
Name:FREDERICK, JASMINE ANN
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:ANN
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 JOHN HANCOCK CT
Mailing Address - Street 2:
Mailing Address - City:NEW WINDSOR
Mailing Address - State:NY
Mailing Address - Zip Code:12553-5015
Mailing Address - Country:US
Mailing Address - Phone:845-863-4011
Mailing Address - Fax:
Practice Address - Street 1:5000 JOHN HANCOCK CT
Practice Address - Street 2:
Practice Address - City:NEW WINDSOR
Practice Address - State:NY
Practice Address - Zip Code:12553-5015
Practice Address - Country:US
Practice Address - Phone:845-863-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist