| Doctor Name: | JACKIE FREDERICK |
| NPI Number: | 1235190885 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | CRNP |
| License Number: | 1-029953 |
| Business Practice Address: | 201 Old Highway 25 E Columbiana, AL - 350519373 |
| Business Phone Number: | 2056694884 |
| Business Fax Number: | 2056694883 |
| Mailing Address: | 110 Indian Forest Trl, PELHAM |
| State: | AL |
| Postal Code: | 351243706 |
| Phone Number: | 2059918422 |
| Fax Number: | 2056694883 |
| NPI Enumeration Date: | 03/31/2006 |
| NPI Last Update Date: | 05/07/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | 1-029953 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | AL |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |