Provider Demographics
NPI:1194597963
Name:DERRICKSON, JAMESHA BRENDA
Entity type:Individual
Prefix:
First Name:JAMESHA
Middle Name:BRENDA
Last Name:DERRICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 E TOWER DR APT 205
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238-2636
Mailing Address - Country:US
Mailing Address - Phone:136-962-7395
Mailing Address - Fax:
Practice Address - Street 1:2704 E TOWER DR APT 205
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-2636
Practice Address - Country:US
Practice Address - Phone:136-962-7395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician