Provider Demographics
NPI:1508964784
Name:HENDERSON, JEFF (PHD)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11464
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-1464
Mailing Address - Country:US
Mailing Address - Phone:928-458-6634
Mailing Address - Fax:928-541-1422
Practice Address - Street 1:1680 W IRON SPRINGS RD
Practice Address - Street 2:SUITE 102
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-3313
Practice Address - Country:US
Practice Address - Phone:928-458-6634
Practice Address - Fax:928-445-2919
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5653842-2501103TC1900X
AZ4041103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling