Provider Demographics
NPI:1689935983
Name:HENDRICKSON, JENNIFER MARIE (PC-IT, SAC-IT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:PC-IT, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 N RANDALL AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-1958
Mailing Address - Country:US
Mailing Address - Phone:608-752-7660
Mailing Address - Fax:608-752-9788
Practice Address - Street 1:612 N RANDALL AVE
Practice Address - Street 2:SUITE A
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-1958
Practice Address - Country:US
Practice Address - Phone:608-752-7660
Practice Address - Fax:608-752-9788
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1434-226101Y00000X
WI16441-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1434-226OtherDEPARTMENT OF SAFETY AND PROFESSIONAL SERVICES
WI16441-130OtherDEPARTMENT OF SAFETY AND PROFESSIONAL SERVICES