Provider Demographics
NPI:1154903920
Name:JOHNSON, DERICK (APRN)
Entity type:Individual
Prefix:MR
First Name:DERICK
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11713 S MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-1524
Mailing Address - Country:US
Mailing Address - Phone:312-380-9808
Mailing Address - Fax:
Practice Address - Street 1:8543 S STONY ISLAND AVE STE 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-2249
Practice Address - Country:US
Practice Address - Phone:312-380-9808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-22
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.022844363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty