Provider Demographics
NPI:1689661662
Name:HENDRIX, JERRY LUCAS (PT)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:LUCAS
Last Name:HENDRIX
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 DALE HAVEN LN
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-8006
Mailing Address - Country:US
Mailing Address - Phone:931-581-8390
Mailing Address - Fax:
Practice Address - Street 1:258 DALE HAVEN LN
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-8006
Practice Address - Country:US
Practice Address - Phone:931-581-8390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17409225100000X
TNPT0000007480261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist