Provider Demographics
NPI:1265104418
Name:DE JEAN, DERRICKA F
Entity type:Individual
Prefix:
First Name:DERRICKA
Middle Name:F
Last Name:DE JEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DERRICKA
Other - Middle Name:F
Other - Last Name:FORTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1321 MURFREESBORO PIKE STE 702
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37217-2679
Mailing Address - Country:US
Mailing Address - Phone:615-361-4000
Mailing Address - Fax:615-815-1946
Practice Address - Street 1:1233 EAGLE LNDNG PKWY STE A&B
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6399
Practice Address - Country:US
Practice Address - Phone:470-231-1149
Practice Address - Fax:615-815-1946
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
GA1-22-62360103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician