Individual
DERRICK JACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LCSW
Contact information
Practice address
2627 CHARLESTOWN RD, NEW ALBANY, IN 47150-2536
(812) 944-1550
Mailing address
2008 ELDER PARK RD, LA GRANGE, KY 40031-9302
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
33008477A
IN
1041C0700X
Clinical Social Worker
Primary
34012719A
IN
Other
Enumeration date
04/29/2019
Last updated
03/11/2026
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