Provider Demographics
NPI:1184182016
Name:DERKSEN, DERRICK JAMES (BA CADC CANDIDATE)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:JAMES
Last Name:DERKSEN
Suffix:
Gender:M
Credentials:BA CADC CANDIDATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 ROYAL AVE
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-2713
Mailing Address - Country:US
Mailing Address - Phone:405-640-5220
Mailing Address - Fax:405-686-7827
Practice Address - Street 1:5401 SW 29TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73179-7602
Practice Address - Country:US
Practice Address - Phone:405-686-7828
Practice Address - Fax:405-686-7827
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator