Provider Demographics
NPI:1730138843
Name:FREDERICKS, RUTH KELLUM (MD)
Entity type:Individual
Prefix:DR
First Name:RUTH
Middle Name:KELLUM
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:MD
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 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-4749
Mailing Address - Fax:601-200-5929
Practice Address - Street 1:971 LAKELAND DR
Practice Address - Street 2:SUITE 557
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4643
Practice Address - Country:US
Practice Address - Phone:601-200-4560
Practice Address - Fax:601-326-4632
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11722174400000X, 2084N0400X
LACOVID19-TMP-4272084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00113670Medicaid
MS130000097Medicare ID - Type Unspecified
MS00113670Medicaid
MS266756YJ9XMedicare PIN
MS130000082Medicare PIN