Provider Demographics
NPI:1982766713
Name:FREDERICK, JAN ELIZABETH (OT, LAC)
Entity Type:Individual
Prefix:MRS
First Name:JAN
Middle Name:ELIZABETH
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:OT, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 GAYLORD ST
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-5398
Mailing Address - Country:US
Mailing Address - Phone:406-560-3497
Mailing Address - Fax:
Practice Address - Street 1:1730 GAYLORD ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-5398
Practice Address - Country:US
Practice Address - Phone:406-560-3497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1067101YA0400X
MT887225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT887OtherOCCUPATIONAL THERAPIST
MT0037245Medicaid
MT1067OtherADDICTION COUNSELOR