Provider Demographics
NPI:1780295170
Name:DERISSE, JAMES
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:DERISSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 SILVER CREEK PL
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-9003
Mailing Address - Country:US
Mailing Address - Phone:904-386-4253
Mailing Address - Fax:
Practice Address - Street 1:2700 UNIVERSITY BLVD W BLDG B
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2147
Practice Address - Country:US
Practice Address - Phone:904-638-9767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX84360101YM0800X
FL22327101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty