Provider Demographics
NPI:1376725291
Name:JACKSON, DERRIKA LYONS (LPC I)
Entity type:Individual
Prefix:MRS
First Name:DERRIKA
Middle Name:LYONS
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 SKYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351
Mailing Address - Country:US
Mailing Address - Phone:936-327-5170
Mailing Address - Fax:
Practice Address - Street 1:201 SKYVIEW DR
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351
Practice Address - Country:US
Practice Address - Phone:936-327-5170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62371101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional