Provider Demographics
NPI:1144968017
Name:FREDERICK, JAYDE MOIRA (LMSW)
Entity type:Individual
Prefix:
First Name:JAYDE MOIRA
Middle Name:
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 1:2043 48TH ST # 1
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-1203
Mailing Address - Country:US
Mailing Address - Phone:347-791-1226
Mailing Address - Fax:
Practice Address - Street 1:58 PALMETTO ST APT 3C
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-8217
Practice Address - Country:US
Practice Address - Phone:347-791-1226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-21
Last Update Date:2022-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111606104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker