=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629507751
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA VIVIANN DERON LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2017
-----------------------------------------------------
Last Update Date | 06/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5205 S MCCOLL RD
-----------------------------------------------------
City | EDINBURG
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78539-7861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-917-9301
-----------------------------------------------------
Fax | 956-265-1358
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1405 E SAMANO ST
-----------------------------------------------------
City | EDINBURG
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78539-4877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-331-2585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180014528
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 178012473
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0019228
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 98090
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------