Provider Demographics
NPI:1417371709
Name:HERNDON, JEFFREY
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:HERNDON
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 1:8701 S HARDY DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-2800
Mailing Address - Country:US
Mailing Address - Phone:602-379-0101
Mailing Address - Fax:480-467-1952
Practice Address - Street 1:8701 S HARDY DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-2800
Practice Address - Country:US
Practice Address - Phone:602-379-0101
Practice Address - Fax:480-467-1952
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-07
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ01752255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer