Provider Demographics
NPI:1528489556
Name:HENDERSON, JENNIFER JOY (RN)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:JOY
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:JOY
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:1 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:NY
Mailing Address - Zip Code:13165-1709
Mailing Address - Country:US
Mailing Address - Phone:315-651-0272
Mailing Address - Fax:315-539-3285
Practice Address - Street 1:1 GROVE ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165-1709
Practice Address - Country:US
Practice Address - Phone:315-651-0272
Practice Address - Fax:315-539-3285
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-17
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY698139163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1528489556Medicaid