Provider Demographics
NPI:1861686123
Name:FREDERICKS, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:@ COLUMBIA DRIVE
Mailing Address - Street 2:J402
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606
Mailing Address - Country:US
Mailing Address - Phone:813-844-7412
Mailing Address - Fax:
Practice Address - Street 1:@ COLUMBIA DRIVE
Practice Address - Street 2:J402
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606
Practice Address - Country:US
Practice Address - Phone:813-844-7412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME106514207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL148MZOtherFL BCBS
FL002280100Medicaid
FL002280100Medicaid