Provider Demographics
NPI:1952075616
Name:FREDERICK, JORDYN
Entity Type:Individual
Prefix:MS
First Name:JORDYN
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 PLEASANT CT APT 3
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-5351
Mailing Address - Country:US
Mailing Address - Phone:434-906-6259
Mailing Address - Fax:
Practice Address - Street 1:1811 JAMESTOWN RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-2326
Practice Address - Country:US
Practice Address - Phone:757-229-9991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program