Basic Information
| Provider Information | |||||||||
| NPI: | 1407123680 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DERSTEIN | ||||||||
| FirstName: | JACKLYN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2561 S GREENWOOD ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672161255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167348855 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2604 W 9TH ST N | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672034731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162954758 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2011 | ||||||||
| LastUpdateDate: | 11/16/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 1250 | KS | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.