Provider Demographics
NPI:1013318138
Name:FREDRICKS, KELLY JO (DC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JO
Last Name:FREDRICKS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JO
Other - Last Name:TELSROW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1290 PALMETTO AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4950
Mailing Address - Country:US
Mailing Address - Phone:407-647-2220
Mailing Address - Fax:407-647-2221
Practice Address - Street 1:1290 PALMETTO AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-4950
Practice Address - Country:US
Practice Address - Phone:407-647-2220
Practice Address - Fax:407-647-2221
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH11311111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor