Provider Demographics
NPI:1205509395
Name:FREDERICKS, COREY JORDAN
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:JORDAN
Last Name:FREDERICKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 ARNOW AVE APT 2C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-7019
Mailing Address - Country:US
Mailing Address - Phone:646-260-2334
Mailing Address - Fax:
Practice Address - Street 1:1601 E MARKET ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27411-0002
Practice Address - Country:US
Practice Address - Phone:718-798-1418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3344567101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC567DP244Medicaid