Provider Demographics
NPI:1013457373
Name:DERRICK, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:DERRICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6312 73RD ST
Mailing Address - Street 2:APT 1510
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-1955
Mailing Address - Country:US
Mailing Address - Phone:940-597-4010
Mailing Address - Fax:
Practice Address - Street 1:6312 73RD ST
Practice Address - Street 2:APT 1510
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-1955
Practice Address - Country:US
Practice Address - Phone:940-597-4010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer