Provider Demographics
NPI:1720040116
Name:HENDERSON, JAN HODGES (PT,MS,PCS)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:HODGES
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PT,MS,PCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 CLARKS CIR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-6614
Mailing Address - Country:US
Mailing Address - Phone:757-966-1631
Mailing Address - Fax:757-953-7134
Practice Address - Street 1:620 JOHN PAUL JONES CIR
Practice Address - Street 2:NAVAL MEDICAL CENTER - PEDIATRICS
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708-2111
Practice Address - Country:US
Practice Address - Phone:757-953-5165
Practice Address - Fax:757-953-7134
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23050022642251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics