Provider Demographics
NPI:1164518668
Name:DERRICKSON, JED E (LCSW-C)
Entity Type:Individual
Prefix:MR
First Name:JED
Middle Name:E
Last Name:DERRICKSON
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2, BOX 155A
Mailing Address - Street 2:
Mailing Address - City:DAGSBORO
Mailing Address - State:DE
Mailing Address - Zip Code:19939
Mailing Address - Country:US
Mailing Address - Phone:302-539-2015
Mailing Address - Fax:
Practice Address - Street 1:505 E MAIN ST
Practice Address - Street 2:Q
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-5020
Practice Address - Country:US
Practice Address - Phone:410-742-8882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD094631041C0700X
DEQ100007441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD298470900Medicaid
MD298470900Medicaid