Provider Demographics
NPI:1164781811
Name:HENDRICKSON, JEFFERSON L (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFERSON
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 1:14964 BELLE AMI DR
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-3600
Mailing Address - Country:US
Mailing Address - Phone:301-498-8455
Mailing Address - Fax:
Practice Address - Street 1:1106 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1637
Practice Address - Country:US
Practice Address - Phone:410-874-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-15
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0080819207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine