Provider Demographics
NPI:1689710402
Name:FREDRICKSON, JENNIFER B (APN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:B
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3964 GOODMAN RD E STE 131
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-8762
Mailing Address - Country:US
Mailing Address - Phone:662-856-8440
Mailing Address - Fax:
Practice Address - Street 1:3964 GOODMAN RD E STE 131
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-8762
Practice Address - Country:US
Practice Address - Phone:662-856-8440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR854891363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01639881Medicaid
MS01639881Medicaid