Provider Demographics
NPI:1821299975
Name:FREDERICK, JAMIE LYNNE (NP)
Entity Type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:LYNNE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:858 CO RD 20
Mailing Address - Street 2:
Mailing Address - City:DILLONVALE
Mailing Address - State:OH
Mailing Address - Zip Code:43917
Mailing Address - Country:US
Mailing Address - Phone:174-073-3728
Mailing Address - Fax:
Practice Address - Street 1:508 MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003
Practice Address - Country:US
Practice Address - Phone:304-243-8916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV51393363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810010317Medicaid
WV3810010317Medicaid