Provider Demographics
NPI:1700248911
Name:FREDRICH, JEREMY
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:FREDRICH
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 1:5477 COUNTRY ROSE CIR
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-9182
Mailing Address - Country:US
Mailing Address - Phone:810-280-2872
Mailing Address - Fax:
Practice Address - Street 1:G3277 BEECHER RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3615
Practice Address - Country:US
Practice Address - Phone:810-282-4278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-26
Last Update Date:2016-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501008920225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist