Provider Demographics
NPI:1609865328
Name:HENDERSON, MARY JANE (GNP)
Entity Type:Individual
Prefix:MS
First Name:MARY JANE
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 ENCINO DR
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-4831
Mailing Address - Country:US
Mailing Address - Phone:831-685-9723
Mailing Address - Fax:408-358-1683
Practice Address - Street 1:15899 LOS GATOS ALMADEN RD
Practice Address - Street 2:SUITE #12
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-3739
Practice Address - Country:US
Practice Address - Phone:408-358-2663
Practice Address - Fax:408-358-1683
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA448450363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ154012Medicare ID - Type Unspecified