Provider Demographics
NPI:1154684975
Name:HENSON, ADAM JORDAN
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:JORDAN
Last Name:HENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-1233
Mailing Address - Country:US
Mailing Address - Phone:618-790-7401
Mailing Address - Fax:
Practice Address - Street 1:916 N WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832
Practice Address - Country:US
Practice Address - Phone:618-790-7401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036137639207Q00000X
IN11016659207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881Medicare UPIN