Provider Demographics
NPI:1982888343
Name:FRED, JAMIE LYNN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:LYNN
Last Name:FRED
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:JAMIE
Other - Middle Name:LYNN
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:REA CLINIC
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822
Mailing Address - Country:US
Mailing Address - Phone:618-724-2401
Mailing Address - Fax:618-724-4628
Practice Address - Street 1:119 GAS PLANT ROAD
Practice Address - Street 2:REA CLINIC-DUQUOIN
Practice Address - City:JOHNSTON CITY
Practice Address - State:IL
Practice Address - Zip Code:62951
Practice Address - Country:US
Practice Address - Phone:618-542-8702
Practice Address - Fax:618-542-8792
Is Sole Proprietor?:No
Enumeration Date:2007-12-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse