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:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 SUMNER ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-1565
Mailing Address - Country:US
Mailing Address - Phone:985-630-1866
Mailing Address - Fax:
Practice Address - Street 1:121 SUMNER ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-1565
Practice Address - Country:US
Practice Address - Phone:985-630-1866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-06
Last Update Date:2025-09-29
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