1528729092 NPI number — KELSEY JACKSON FREDERICKS LAT, ATC

Table of content: KELSEY JACKSON FREDERICKS LAT, ATC (NPI 1528729092)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528729092 NPI number — KELSEY JACKSON FREDERICKS LAT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREDERICKS
Provider First Name:
KELSEY
Provider Middle Name:
JACKSON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LAT, ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528729092
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2005 MILLER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLOVIS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88101-8660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-269-5962
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2005 MILLER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLOVIS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88101-8660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-269-5962
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/06/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  AT656 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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