Provider Demographics
NPI:1386986412
Name:HENDERSON, JENNIFER LEE (PHD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LEE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E. 16TH STREET
Mailing Address - Street 2:INNOVATIVE HEALTH CARE CONCEPTS INC.
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401
Mailing Address - Country:US
Mailing Address - Phone:208-529-8526
Mailing Address - Fax:
Practice Address - Street 1:111 E. 16TH STREET
Practice Address - Street 2:INNOVATIVE HEALTH CARE CONCEPTS INC.
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401
Practice Address - Country:US
Practice Address - Phone:208-529-8526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-27
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IDPSY-203029103TC0700X
VA0810005625103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103T00000XBehavioral Health & Social Service ProvidersPsychologist