Provider Demographics
NPI:1659983112
Name:HENDERSON, JAELANI DESERAE
Entity Type:Individual
Prefix:
First Name:JAELANI
Middle Name:DESERAE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 CRAWFORD ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02121-1017
Mailing Address - Country:US
Mailing Address - Phone:617-322-4046
Mailing Address - Fax:
Practice Address - Street 1:192 THROOP AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-5334
Practice Address - Country:US
Practice Address - Phone:929-210-9333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health