Provider Demographics
NPI:1598017030
Name:HENDRICKS, JEFFREY GRANGER
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:GRANGER
Last Name:HENDRICKS
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 1:5450 W OUTER DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1485
Mailing Address - Country:US
Mailing Address - Phone:313-861-8515
Mailing Address - Fax:313-341-9801
Practice Address - Street 1:5450 W OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-1485
Practice Address - Country:US
Practice Address - Phone:313-861-8515
Practice Address - Fax:313-341-9801
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401003783101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional