Provider Demographics
NPI:1093423337
Name:JACKSON, DERIC R (LICSW)
Entity Type:Individual
Prefix:MR
First Name:DERIC
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 S FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-2684
Mailing Address - Country:US
Mailing Address - Phone:651-500-0905
Mailing Address - Fax:
Practice Address - Street 1:1320 S FRONTAGE RD STE 200
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033-2481
Practice Address - Country:US
Practice Address - Phone:651-500-0905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN215441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical