Provider Demographics
NPI:1972870988
Name:FRIEDRIKSON, JACKIE (CMT)
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:
Last Name:FRIEDRIKSON
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E YOSEMITE AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-5755
Mailing Address - Country:US
Mailing Address - Phone:209-483-8913
Mailing Address - Fax:
Practice Address - Street 1:300 E YOSEMITE AVE STE 107
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-5755
Practice Address - Country:US
Practice Address - Phone:209-483-8913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-18
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89944174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist