Provider Demographics
NPI:1588460729
Name:LARICK, JEDEDIAH (LCDC)
Entity type:Individual
Prefix:MR
First Name:JEDEDIAH
Middle Name:
Last Name:LARICK
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 N CLAY ST APT 1
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75119-2346
Mailing Address - Country:US
Mailing Address - Phone:956-933-0709
Mailing Address - Fax:
Practice Address - Street 1:1207 N CLAY ST APT 1
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119-2346
Practice Address - Country:US
Practice Address - Phone:956-933-0709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-19
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14222101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX14222OtherLICENSED CHEMICAL DEPENDENCY COUNSELOR