Provider Demographics
NPI:1285403550
Name:HENDERSON, JACOB ANDREW
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ANDREW
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 BETHEL PARK DR
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:OH
Mailing Address - Zip Code:45106-9300
Mailing Address - Country:US
Mailing Address - Phone:513-301-3295
Mailing Address - Fax:
Practice Address - Street 1:23 BETHEL PARK DR
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:OH
Practice Address - Zip Code:45106-9300
Practice Address - Country:US
Practice Address - Phone:513-301-3295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No172A00000XOther Service ProvidersDriver
No253Z00000XAgenciesIn Home Supportive Care
No376J00000XNursing Service Related ProvidersHomemaker
No385H00000XRespite Care FacilityRespite Care