Provider Demographics
NPI:1942951686
Name:DERDERIAN, JENNA (LCMHC, LCASA)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:DERDERIAN
Suffix:
Gender:F
Credentials:LCMHC, LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 CLANTON RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-1309
Mailing Address - Country:US
Mailing Address - Phone:704-332-9001
Mailing Address - Fax:
Practice Address - Street 1:10430 HARRIS OAK BLVD STE L
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-7513
Practice Address - Country:US
Practice Address - Phone:704-360-3637
Practice Address - Fax:704-200-9829
Is Sole Proprietor?:No
Enumeration Date:2022-01-14
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-27654101YA0400X
NC18014101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)