Provider Demographics
NPI:1396225504
Name:ERICKSON, JEREMY (MAMFTC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:MAMFTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 GOODMAN RD W STE 305
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-8004
Mailing Address - Country:US
Mailing Address - Phone:662-856-9563
Mailing Address - Fax:
Practice Address - Street 1:232 GOODMAN RD W STE 305
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-8004
Practice Address - Country:US
Practice Address - Phone:662-856-9563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2608101YP2500X
ARA1708258101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty