Provider Demographics
NPI:1104328111
Name:HENDRICKSON, JENNY MARIE (RDH, DT)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:MARIE
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:RDH, DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PERHAM
Mailing Address - State:MN
Mailing Address - Zip Code:56573-2118
Mailing Address - Country:US
Mailing Address - Phone:218-346-7186
Mailing Address - Fax:218-346-7182
Practice Address - Street 1:918 MARKET ST
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-2118
Practice Address - Country:US
Practice Address - Phone:218-346-7186
Practice Address - Fax:218-346-7182
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT99125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist