Provider Demographics
NPI:1063098234
Name:HENDRICKSON, JEAN (LCSW R CASAC)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:LCSW R CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 KNIGHTSBRIDGE UNIT A
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-3603
Mailing Address - Country:US
Mailing Address - Phone:845-416-4293
Mailing Address - Fax:
Practice Address - Street 1:14 KNIGHTSBRIDGE UNIT A
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-3603
Practice Address - Country:US
Practice Address - Phone:845-416-4293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052594101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY052594OtherLICENSE SOCIAL WORK