Healthcare Provider Details

I. General information

NPI: 1154903920
Provider Name (Legal Business Name): DERICK JOHNSON APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8543 S STONY ISLAND AVE STE 3
CHICAGO IL
60617-2249
US

IV. Provider business mailing address

11713 S MAPLEWOOD AVE
CHICAGO IL
60655-1524
US

V. Phone/Fax

Practice location:
  • Phone: 312-380-9808
  • Fax:
Mailing address:
  • Phone: 312-380-9808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number286201
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.022844
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: