Provider Demographics
NPI:1699447102
Name:FREDERICK, JADE ELIZABETH (LMSW)
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:ELIZABETH
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1269 WOODFIELD STREET
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22900 FEDERAL AVENUE HENRY FORD HEALTH SYSTEM CLINIC
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089
Practice Address - Country:US
Practice Address - Phone:248-266-0475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-03
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MI68010950951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty