MEDICARE: SALEM ISABELLA DERDOCK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		FL

General Provider Information

NPI Number	:	1124986534
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SALEM ISABELLA DERDOCK

Provider Business Mailing Address
First Line	:	12276 SAN JOSE BLVD STE 508
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-8618
Country	:	US
Telephone Number	:	904-886-3228
Fax Number	:	904-485-8876

Provider Business Practice Location Address
First Line	:	12276 SAN JOSE BLVD STE 508
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-8618
Country	:	US
Telephone Number	:	904-886-3228
Fax Number	:	904-485-8876

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2026
Last Update Date	:	01/13/2026

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Directions to “ SALEM ISABELLA DERDOCK ” Practice Location

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