Provider Demographics
NPI:1437452018
Name:HENDRICKSON, JORDAN MICHELLE (PSYD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:MICHELLE
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:MICHELLE
Other - Last Name:LUTEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4400 NE 77TH AVE STE 275
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6857
Mailing Address - Country:US
Mailing Address - Phone:503-709-3295
Mailing Address - Fax:
Practice Address - Street 1:4400 NE 77TH AVE STE 275
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6857
Practice Address - Country:US
Practice Address - Phone:503-709-3295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-21
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60949986103TC0700X
MTPSYPSYLIC3612103TC0700X
OR2608103TC0700X
390200000X
OR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program