Provider Demographics
NPI:1710654777
Name:FREDRIKSEN, JACLYN CAROL (PHD, LMHC, LMFT)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:CAROL
Last Name:FREDRIKSEN
Suffix:
Gender:F
Credentials:PHD, LMHC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:FORT PLAIN
Mailing Address - State:NY
Mailing Address - Zip Code:13339-9998
Mailing Address - Country:US
Mailing Address - Phone:607-677-4052
Mailing Address - Fax:
Practice Address - Street 1:3212 COUNTY HIGHWAY 31
Practice Address - Street 2:
Practice Address - City:CHERRY VALLEY
Practice Address - State:NY
Practice Address - Zip Code:13320-3702
Practice Address - Country:US
Practice Address - Phone:607-677-4052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002156101YM0800X
NY012161101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health