Provider Demographics
NPI:1104079219
Name:HENDERSON, JENNIFER JEAN (LMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JEAN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 WINSLOW BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AR
Mailing Address - Zip Code:72959
Mailing Address - Country:US
Mailing Address - Phone:479-841-2081
Mailing Address - Fax:479-634-5109
Practice Address - Street 1:341 WINSLOW BLVD
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AR
Practice Address - Zip Code:72959
Practice Address - Country:US
Practice Address - Phone:479-841-2081
Practice Address - Fax:479-634-5109
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2176174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist