Provider Demographics
NPI:1164831814
Name:HENDERSHOT, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:HENDERSHOT
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 1:1225 WOODLAND DR
Mailing Address - Street 2:THERAPY DEPT
Mailing Address - City:MT ZION
Mailing Address - State:IL
Mailing Address - Zip Code:62549-1237
Mailing Address - Country:US
Mailing Address - Phone:217-864-2356
Mailing Address - Fax:
Practice Address - Street 1:1225 WOODLAND DR
Practice Address - Street 2:THERAPY DEPT
Practice Address - City:MT ZION
Practice Address - State:IL
Practice Address - Zip Code:62549-1237
Practice Address - Country:US
Practice Address - Phone:217-864-2356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.001330224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant