Basic Information
| Provider Information | |||||||||
| NPI: | 1528359734 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DERRY | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3205 N ACADEMY BLVD STE 130 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809175152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196325700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 350 LYCKMAN PL | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808172861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196325700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2011 | ||||||||
| LastUpdateDate: | 03/21/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 2009024349 | MO | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | LPC.0003637 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.