Provider Demographics
NPI:1164993465
Name:HENDERSON, JACQUELENE (LMHC)
Entity Type:Individual
Prefix:
First Name:JACQUELENE
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 415
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02840-0400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1341 WEST MAIN ROAD
Practice Address - Street 2:SUITE 16
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840
Practice Address - Country:US
Practice Address - Phone:401-862-0190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-12
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
RIMHC01001101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health