Provider Demographics
NPI:1689373805
Name:HENRIKSON, JILL LYNN
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:LYNN
Last Name:HENRIKSON
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 1:6227 PUTTYGUT RD
Mailing Address - Street 2:
Mailing Address - City:CHINA
Mailing Address - State:MI
Mailing Address - Zip Code:48054-1804
Mailing Address - Country:US
Mailing Address - Phone:810-326-4339
Mailing Address - Fax:
Practice Address - Street 1:4220 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:EAST CHINA
Practice Address - State:MI
Practice Address - Zip Code:48054-2200
Practice Address - Country:US
Practice Address - Phone:586-292-5207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001269208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation