Provider Demographics
NPI:1497896674
Name:JOHNSON, DERRICK JAMES (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:JAMES
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 MADISON
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1022 MADISON
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302
Practice Address - Country:US
Practice Address - Phone:708-802-1303
Practice Address - Fax:708-386-8602
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004135101YP2500X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical