Provider Demographics
NPI:1710956024
Name:HENDRICK, JASON PAUL (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:PAUL
Last Name:HENDRICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:877-668-5621
Mailing Address - Fax:
Practice Address - Street 1:2800 FERRY ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-447-9749
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048930A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN9397123OtherPHCS PID NUMBER
IN000000190918OtherANTHEM PROVIDER NUMBER
IN10825254OtherCAQH NUMBER
IN200283760Medicaid
IN090670HMedicare PIN
IN000000190918OtherANTHEM PROVIDER NUMBER
IN200283760Medicaid
IN9397123OtherPHCS PID NUMBER