Provider Demographics
NPI:1538879671
Name:FREDERICK, JESSICA MARIA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MARIA
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MALVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11565-1336
Mailing Address - Country:US
Mailing Address - Phone:516-444-2211
Mailing Address - Fax:
Practice Address - Street 1:7625 W 92ND AVE
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80021-4567
Practice Address - Country:US
Practice Address - Phone:303-252-7790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0884021041C0700X
COCSW.099287501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical