Provider Demographics
NPI:1497827836
Name:JEFFREY, DERREL (LCSW)
Entity Type:Individual
Prefix:
First Name:DERREL
Middle Name:
Last Name:JEFFREY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4906 LAKE ENGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-2938
Mailing Address - Country:US
Mailing Address - Phone:254-218-2389
Mailing Address - Fax:855-396-2470
Practice Address - Street 1:345 OWEN LN STE 122
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-5583
Practice Address - Country:US
Practice Address - Phone:254-218-2389
Practice Address - Fax:855-396-2470
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2020-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX355971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178626101Medicaid