Provider Demographics
NPI:1063676062
Name:HENDRICKS, JENNIFER LEIGH (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEIGH
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11371 ELDORADO ST NE UNIT D
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4550
Mailing Address - Country:US
Mailing Address - Phone:763-464-8610
Mailing Address - Fax:
Practice Address - Street 1:9055 SPRINGBROOK DR NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5841
Practice Address - Country:US
Practice Address - Phone:763-780-6580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10504363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant