Provider Demographics
NPI:1427770403
Name:HENDERSON, KELLY JEAN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
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 1:12703 CLOVERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-2032
Mailing Address - Country:US
Mailing Address - Phone:832-814-1362
Mailing Address - Fax:
Practice Address - Street 1:10300 JONES RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77065-4208
Practice Address - Country:US
Practice Address - Phone:281-897-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-15
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110633235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1609917541Medicaid