Provider Demographics
NPI:1154610152
Name:HENDERSON, JOLETTA KEMP
Entity type:Individual
Prefix:
First Name:JOLETTA
Middle Name:KEMP
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6393 GREEN GROVE DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38141-7158
Mailing Address - Country:US
Mailing Address - Phone:901-282-7738
Mailing Address - Fax:
Practice Address - Street 1:6393 GREEN GROVE DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38141-7158
Practice Address - Country:US
Practice Address - Phone:901-282-7738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-31
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN64592171W00000X, 171WH0202X
ARPTA 1579225200000X
MSPTA4329225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WH0202XOther Service ProvidersContractorHome Modifications
No171W00000XOther Service ProvidersContractor
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ057969Medicaid