Provider Demographics
NPI:1326009739
Name:HENRIKSON, JEAN LYNN (NP)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:LYNN
Last Name:HENRIKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3371 KNICKERBOCKER RD # 236
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-6814
Mailing Address - Country:US
Mailing Address - Phone:325-703-6670
Mailing Address - Fax:325-703-6672
Practice Address - Street 1:2133 OFFICE PARK DR STE A
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904
Practice Address - Country:US
Practice Address - Phone:325-703-6670
Practice Address - Fax:325-703-6672
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX668149363L00000X
TXAP110098363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164744808Medicaid
TX164744801Medicaid
TX8B4824Medicare PIN