Provider Demographics
NPI:1376192823
Name:HENDERSON, JACKIE D
Entity Type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:D
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7041 HEDGEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75249
Mailing Address - Country:US
Mailing Address - Phone:972-822-8115
Mailing Address - Fax:
Practice Address - Street 1:7041 HEDGEBROOK DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75249
Practice Address - Country:US
Practice Address - Phone:972-822-8115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-07
Last Update Date:2019-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities