Provider Demographics
NPI:1912926601
Name:JOHN, DEREK JEREMY (PHD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:JEREMY
Last Name:JOHN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-5524
Mailing Address - Country:US
Mailing Address - Phone:715-842-0944
Mailing Address - Fax:715-845-6477
Practice Address - Street 1:631 FOREST ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-5524
Practice Address - Country:US
Practice Address - Phone:715-842-0944
Practice Address - Fax:715-845-6477
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2306-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI87249OtherSECURITY HEALTH INSURANCE
332603OtherMANAGED HEALTH NETWORK
2187795OtherCIGNA BEHAVIORAL HEALTH