Provider Demographics
NPI:1699775593
Name:HENDRICKSON, JOHN L (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:HENDRICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 FENWICK DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-2112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3300 RIVERMONT AVE
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24503-2030
Practice Address - Country:US
Practice Address - Phone:434-200-5999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010530662084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
O87204OtherSENTARA/OPTIMA PROVIDER N
186463OtherANTHEM PROVIDER NUMBER
203639329001OtherTRICARE PROVIDER NUMBER
2016147OtherCIGNA BEHAVIOR PROVIDER N
132551OtherVALUE OPTIONS PROVIDER NU
186463OtherANTHEM PROVIDER NUMBER
2016147OtherCIGNA BEHAVIOR PROVIDER N