Provider Demographics
NPI:1649854803
Name:PREJEAN, DERRICK JONES (RBT)
Entity type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:JONES
Last Name:PREJEAN
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 GARDEN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3585
Mailing Address - Country:US
Mailing Address - Phone:404-788-2854
Mailing Address - Fax:
Practice Address - Street 1:3760 LAVISTA RD STE 102
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5622
Practice Address - Country:US
Practice Address - Phone:678-626-0557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician