Provider Demographics
NPI:1275680720
Name:HENDRICKSON, JODI DENEE (PT)
Entity Type:Individual
Prefix:DR
First Name:JODI
Middle Name:DENEE
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4272 AUBURN AVE
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8428
Mailing Address - Country:US
Mailing Address - Phone:701-893-6776
Mailing Address - Fax:
Practice Address - Street 1:3060 FRONTIER WAY
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8909
Practice Address - Country:US
Practice Address - Phone:701-232-2340
Practice Address - Fax:701-232-2330
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND14312251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND28235OtherBCBS ALL STATES
ND51421Medicaid
64-07780OtherMEDICA/UNITED HEALTH
HP78396OtherHEALTH PARTNERS CIGNA
1083461OtherCOVENTRY
28235OtherNORIDIAN BPA
NDA016OtherTRICARE