Provider Demographics
NPI:1396379525
Name:HENDRICKSON, JEREMY ROBERT (APRN)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:ROBERT
Last Name:HENDRICKSON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 E 29TH ST STE 260
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2587
Mailing Address - Country:US
Mailing Address - Phone:979-821-6300
Mailing Address - Fax:979-823-4545
Practice Address - Street 1:2700 E 29TH ST STE 260
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2587
Practice Address - Country:US
Practice Address - Phone:979-774-0012
Practice Address - Fax:979-774-4636
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95155222163W00000X
NE91079163WC0200X
TX844664163WC0200X
IAH158450363L00000X
NE113125363L00000X
TXAP145332363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner