Provider Demographics
NPI:1932501244
Name:HEIDERICH, JERRY W (LMFT)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:W
Last Name:HEIDERICH
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 FAIRWAY MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75044-5069
Mailing Address - Country:US
Mailing Address - Phone:214-862-8964
Mailing Address - Fax:
Practice Address - Street 1:723 S I 35 E STE 110
Practice Address - Street 2:DENTON SQUARE BUSINESS CENTER
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76205-4102
Practice Address - Country:US
Practice Address - Phone:940-483-1789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4760106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist