Healthcare Provider Details

I. General information

NPI: 1396901757
Provider Name (Legal Business Name): DERICK B PALMER ED.D, LPC, LMHC, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 A 2ND ST SE
KIRTLAND AFB NM
87117-5901
US

IV. Provider business mailing address

9730 HIGHWAY 238
JACKSONVILLE OR
97530-9601
US

V. Phone/Fax

Practice location:
  • Phone: 505-846-3200
  • Fax:
Mailing address:
  • Phone: 541-841-8591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberRC60018183
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60210091
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number713
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: