Healthcare Provider Details

I. General information

NPI: 1912828732
Provider Name (Legal Business Name): DERRIONN SHAUNTI ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2026
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3027 SAN DIEGO RD
JACKSONVILLE FL
32207-3691
US

IV. Provider business mailing address

6867 RESTLAWN DR
JACKSONVILLE FL
32208-2568
US

V. Phone/Fax

Practice location:
  • Phone: 904-859-6028
  • Fax:
Mailing address:
  • Phone: 904-859-6028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: