Provider Demographics
NPI:1093836033
Name:HENDERSON, JENNIFER LYNN (RN, CDE)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:RN, CDE
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:GEORGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:222 TONGASS DR
Mailing Address - Street 2:
Mailing Address - City:SITKA
Mailing Address - State:AK
Mailing Address - Zip Code:99835-9416
Mailing Address - Country:US
Mailing Address - Phone:907-966-8595
Mailing Address - Fax:907-966-8848
Practice Address - Street 1:222 TONGASS DR
Practice Address - Street 2:
Practice Address - City:SITKA
Practice Address - State:AK
Practice Address - Zip Code:99835-9416
Practice Address - Country:US
Practice Address - Phone:907-966-8595
Practice Address - Fax:907-966-8848
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK11824163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK8EA917Medicare PIN
AKQ24464Medicare UPIN
AK8EA918Medicare PIN
AK8EA915Medicare PIN
AK8EA916Medicare PIN
AK8EA914Medicare PIN