Provider Demographics
NPI:1528729092
Name:FREDERICKS, KELSEY JACKSON (LAT, ATC)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:JACKSON
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 MILLER ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-8660
Mailing Address - Country:US
Mailing Address - Phone:505-269-5962
Mailing Address - Fax:
Practice Address - Street 1:2005 MILLER ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-8660
Practice Address - Country:US
Practice Address - Phone:505-269-5962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMAT6562255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty