Healthcare Provider Details

I. General information

NPI: 1235625377
Provider Name (Legal Business Name): DEREK KENNETH MIXON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4776 HODGES BLVD STE 101
JACKSONVILLE FL
32224-7218
US

IV. Provider business mailing address

4776 HODGES BLVD STE 101
JACKSONVILLE FL
32224-7218
US

V. Phone/Fax

Practice location:
  • Phone: 904-223-2363
  • Fax: 904-223-2365
Mailing address:
  • Phone: 904-223-2363
  • Fax: 904-223-2365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: