Provider Demographics
NPI:1316655343
Name:FREDERICK, JASON PAUL (RN)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:PAUL
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 GRANSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:BELLA VISTA
Mailing Address - State:AR
Mailing Address - Zip Code:72714-4917
Mailing Address - Country:US
Mailing Address - Phone:479-633-3269
Mailing Address - Fax:
Practice Address - Street 1:119 GRANSHIRE DR
Practice Address - Street 2:
Practice Address - City:BELLA VISTA
Practice Address - State:AR
Practice Address - Zip Code:72714-4917
Practice Address - Country:US
Practice Address - Phone:479-633-3269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR095610163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse