Individual
JENNIFER S FREDERICKS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
820 S IL ROUTE 59, BARTLETT, IL 60103-1694
(630) 483-5930
(630) 483-5939
Mailing address
820 S IL ROUTE 59, BARTLETT, IL 60103-1694
(630) 483-5930
(630) 483-5939
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
036106524
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0222075
BLUE CROSS GROUP NUMBER
IL
05
—
036106524
—
ID
01
—
36-3149833
TAX IDENTIFICATION NUMBER
ID
01
—
3631498336019001
CDPG HFS PAYEE ID
IL
Enumeration date
06/29/2006
Last updated
04/04/2013
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