Provider Demographics
NPI:1609482553
Name:HENDERSON, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
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 1:21525 HWY 410 E STE B
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-4101
Mailing Address - Country:US
Mailing Address - Phone:253-826-8520
Mailing Address - Fax:
Practice Address - Street 1:21525 HWY 410 E STE B
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-4101
Practice Address - Country:US
Practice Address - Phone:253-826-8520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist