Provider Demographics
NPI:1356098438
Name:DERRICK, BENJAMIN DAVID (BIBLICAL COUNSELOR)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:DAVID
Last Name:DERRICK
Suffix:
Gender:M
Credentials:BIBLICAL COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 BUCKHEAD DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6615
Mailing Address - Country:US
Mailing Address - Phone:601-405-7440
Mailing Address - Fax:
Practice Address - Street 1:4500 INTERSTATE 55 NORTH FRONTAGE RD
Practice Address - Street 2:STE 279
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211
Practice Address - Country:US
Practice Address - Phone:601-405-7445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10102004101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral