Provider Demographics
NPI:1477203164
Name:HENDERSON, JACK RYAN
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:RYAN
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 1:4770 BASELINE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2668
Mailing Address - Country:US
Mailing Address - Phone:970-982-3476
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:4770 BASELINE RD STE 200
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2668
Practice Address - Country:US
Practice Address - Phone:970-982-3476
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician