Provider Demographics
NPI:1689688285
Name:FREDENBERG, JASON R (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:R
Last Name:FREDENBERG
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 GREENE CO OFFICE BLDG
Mailing Address - Street 2:GREENE CO MENTAL HEALTH CLINIC
Mailing Address - City:CAIRO
Mailing Address - State:NY
Mailing Address - Zip Code:12413-2868
Mailing Address - Country:US
Mailing Address - Phone:518-622-9163
Mailing Address - Fax:518-622-8592
Practice Address - Street 1:905 GREENE CO OFFICE BLDG
Practice Address - Street 2:GREENE CO MENTAL HEALTH CLINIC
Practice Address - City:CAIRO
Practice Address - State:NY
Practice Address - Zip Code:12413-2868
Practice Address - Country:US
Practice Address - Phone:518-622-9163
Practice Address - Fax:518-622-8592
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015573103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY015573OtherLICENSE NO