Provider Demographics
NPI:1083289243
Name:DERRICKSON, JACOB EARON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:EARON
Last Name:DERRICKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18785 MCCOY RD
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:LA
Mailing Address - Zip Code:70754-5616
Mailing Address - Country:US
Mailing Address - Phone:225-303-7452
Mailing Address - Fax:
Practice Address - Street 1:258 ARCENEAUX RD
Practice Address - Street 2:
Practice Address - City:CARENCRO
Practice Address - State:LA
Practice Address - Zip Code:70520-6220
Practice Address - Country:US
Practice Address - Phone:337-520-0672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7181122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist