Deric R Jackson, LICSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

21544 Issued in MN

Practice address

1320 S Frontage Rd Ste 200
Hastings, MN 55033-2481

Phone

(651) 500-0905

NPI assigned

Nov 7, 2022

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Minnesota Counseling and Therapy Center, Inc

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Bloomington, MN
  • NPI 1659761633
  Medicare reassignment NPD
• Psychotherapy & Healing Associates

  • Psychologist
  • St Louis Park, MN
  • NPI 1801028972
  NPD (past)
• Tom Lutz & Associates

  • Psychologist
  • Hastings, MN
  • NPI 1629347273
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1667779200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1669593600000",
    "number": "1093423337",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1320 S FRONTAGE RD",
            "city": "HASTINGS",
            "state": "MN",
            "postal_code": "550332684",
            "telephone_number": "651-500-0905"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1320 S FRONTAGE RD STE 200",
            "city": "HASTINGS",
            "state": "MN",
            "postal_code": "550332481",
            "telephone_number": "651-500-0905"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "DERIC",
        "middle_name": "R",
        "name_prefix": "Mr.",
        "credential": "LICSW",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2022-11-07",
        "last_updated": "2022-11-28",
        "certification_date": "2022-11-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MN",
            "license": "21544",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Independent Endeavors LLC
• Independent School District 200
• Insights Psychology, LLC
• Tricia Wallentine Ische, PA-C
• Derek Cameron Jackson, M.D.
• Jarvis Paul Jackson
• Tanner Jackson, DDS
• Madeline Jeppesen
• Jing River Acupuncture and Traditional Medicine, LLC
• Tammy J John, N.P.

• Clinical Social Worker in Hastings, MN
• Providers in Hastings, MN by specialty
• Clinical Social Worker in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 28, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.