Provider Demographics
NPI:1669689295
Name:FREDERICKS, JASON MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:MICHAEL
Last Name:FREDERICKS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8200 HUMBOLDT AVE S
Mailing Address - Street 2:STE 204
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-1432
Mailing Address - Country:US
Mailing Address - Phone:612-386-0333
Mailing Address - Fax:
Practice Address - Street 1:8200 HUMBOLDT AVE S STE 204
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-1432
Practice Address - Country:US
Practice Address - Phone:952-884-6144
Practice Address - Fax:952-884-9180
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3651111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5328276-00Medicaid
MN5328276-00Medicaid
MNU73289Medicare UPIN