Provider Demographics
NPI:1659728814
Name:FRAZIER, JAE LINDSEY
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:LINDSEY
Last Name:FRAZIER
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 1:97 LONGKILL RD
Mailing Address - Street 2:
Mailing Address - City:BALLSTON LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12019-1615
Mailing Address - Country:US
Mailing Address - Phone:518-542-2822
Mailing Address - Fax:
Practice Address - Street 1:3855 DARTMOUTH COLLEGE HWY
Practice Address - Street 2:
Practice Address - City:NORTH HAVERHILL
Practice Address - State:NH
Practice Address - Zip Code:03774-4937
Practice Address - Country:US
Practice Address - Phone:603-787-6971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60770804225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist