Provider Demographics
NPI:1023353711
Name:DERRICK, JESSICA (LMP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DERRICK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7492 S FRANCESCO WAY APT F201
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-4940
Mailing Address - Country:US
Mailing Address - Phone:801-574-7692
Mailing Address - Fax:
Practice Address - Street 1:7604 NE 5TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-8204
Practice Address - Country:US
Practice Address - Phone:360-314-4380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60276976225700000X
UT225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist