Provider Demographics
NPI:1699115485
Name:FREDERICK, JASON STANLEY (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:STANLEY
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 10TH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-3600
Mailing Address - Country:US
Mailing Address - Phone:706-571-1430
Mailing Address - Fax:706-571-1604
Practice Address - Street 1:1800 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1513
Practice Address - Country:US
Practice Address - Phone:706-571-1120
Practice Address - Fax:706-571-1603
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME164903208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation