Provider Demographics
NPI:1871792697
Name:DERRICK, JAMIE C (PHD)
Entity type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:C
Last Name:DERRICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:JAMIE
Other - Middle Name:C
Other - Last Name:NEKICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:875 PERIMETER DR
Mailing Address - Street 2:UNIVERSITY OF IDAHO, MS 3043 (PSYCHOLOGY DEPT)
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83844-3043
Mailing Address - Country:US
Mailing Address - Phone:208-885-5057
Mailing Address - Fax:
Practice Address - Street 1:875 PERIMETER DR
Practice Address - Street 2:DEPT. OF PSYCHOLOGY, UNIVERSITY OF IDAHO, MS 3043
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83844-9803
Practice Address - Country:US
Practice Address - Phone:208-885-5057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY325103T00000X
CAPSY14487103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist