Provider Demographics
NPI:1366617292
Name:FREDERICKSON, JENNY D (PT)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:D
Last Name:FREDERICKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9601 I-630 EXIT 7
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-7202
Mailing Address - Country:US
Mailing Address - Phone:501-202-7683
Mailing Address - Fax:501-202-7007
Practice Address - Street 1:9601 I-630 EXIT 7
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7202
Practice Address - Country:US
Practice Address - Phone:501-202-7683
Practice Address - Fax:501-202-7007
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT1445225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist