Provider Demographics
NPI:1912367806
Name:FREDETTE, JENNIFER (MA, MDIV)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FREDETTE
Suffix:
Gender:F
Credentials:MA, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX QQ
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-0700
Mailing Address - Country:US
Mailing Address - Phone:703-903-9696
Mailing Address - Fax:
Practice Address - Street 1:1716 CHAIN BRIDGE RD
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-4322
Practice Address - Country:US
Practice Address - Phone:703-903-9696
Practice Address - Fax:703-821-2505
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-04
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X, 101YM0800X
VA0701006603101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional