Provider Demographics
NPI:1265018428
Name:HENDERSON, JEREMIAH
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:HENDERSON
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 1:1800 FM 2625 E
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75672-3793
Mailing Address - Country:US
Mailing Address - Phone:903-263-8485
Mailing Address - Fax:
Practice Address - Street 1:1800 FM 2625 E
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75672-3793
Practice Address - Country:US
Practice Address - Phone:903-263-8485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX635271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical