Provider Demographics
NPI:1487863999
Name:HENDERSON, PHYLLIS JO (MD)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:JO
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20980 STATE ROUTE 410
Mailing Address - Street 2:
Mailing Address - City:NACHES
Mailing Address - State:WA
Mailing Address - Zip Code:98937-9173
Mailing Address - Country:US
Mailing Address - Phone:509-658-1776
Mailing Address - Fax:
Practice Address - Street 1:402 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3546
Practice Address - Country:US
Practice Address - Phone:808-575-4084
Practice Address - Fax:509-575-4234
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261262084A0401X
WAWA261262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG18806143Medicare PIN