Provider Demographics
NPI:1336942036
Name:RIDDICK, KHADEESHA JACKE' (MS)
Entity type:Individual
Prefix:
First Name:KHADEESHA
Middle Name:JACKE'
Last Name:RIDDICK
Suffix:
Gender:
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2418 S HOLDEN RD APT D
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-5730
Mailing Address - Country:US
Mailing Address - Phone:334-413-3447
Mailing Address - Fax:
Practice Address - Street 1:2418 S HOLDEN RD APT D
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-5730
Practice Address - Country:US
Practice Address - Phone:334-413-3447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-28
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor