Provider Demographics
NPI:1992522593
Name:FREDERICKS, COURTNEY JESSICA
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:JESSICA
Last Name:FREDERICKS
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 ROOSEVELT AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-2687
Mailing Address - Country:US
Mailing Address - Phone:360-939-1450
Mailing Address - Fax:
Practice Address - Street 1:1420 ROOSEVELT AVE STE 2
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-2687
Practice Address - Country:US
Practice Address - Phone:360-939-1450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health