Provider Demographics
NPI:1356611339
Name:FREDERICK, JEANNINE F (NP)
Entity type:Individual
Prefix:MS
First Name:JEANNINE
Middle Name:F
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3370
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70434-3370
Mailing Address - Country:US
Mailing Address - Phone:985-400-5988
Mailing Address - Fax:985-256-5687
Practice Address - Street 1:1970 N HIGHWAY 190
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-5364
Practice Address - Country:US
Practice Address - Phone:985-892-5355
Practice Address - Fax:985-256-5687
Is Sole Proprietor?:No
Enumeration Date:2012-01-06
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN078775-AP05838363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2349988Medicaid