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General NPI Number Information
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NPI Number | 1164518668
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Entity Type | Individual
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Provider Name | JED E. DERRICKSON LCSW-C
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Gender | Male
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Dates
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Enumeration Date | 10/04/2006
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Last Update Date | 10/18/2016
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Provider Practice Location Address
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Address Line | 505 E MAIN ST Q
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City | SALISBURY
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State | MD
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Zip | 21804-5020
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Country | US
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Telephone | 410-742-8882
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Fax |
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Provider Business Mailing Address
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Address Line | RR 2, BOX 155A
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City | DAGSBORO
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State | DE
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Zip | 19939
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Country | US
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Telephone | 302-539-2015
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 09463
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | Q10000744
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License Number State | DE
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