Provider Demographics
NPI:1770507576
Name:HENDRICKS, JASON JOSEPH (MPT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:JOSEPH
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 MAIN DUNSTABLE RD
Mailing Address - Street 2:SUITE 155
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03060-3640
Mailing Address - Country:US
Mailing Address - Phone:603-881-5554
Mailing Address - Fax:603-595-7511
Practice Address - Street 1:155 MAIN DUNSTABLE RD
Practice Address - Street 2:SUITE 155
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-3640
Practice Address - Country:US
Practice Address - Phone:603-881-5554
Practice Address - Fax:603-595-7511
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3145225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHHE-RE8869Medicare ID - Type UnspecifiedMEDICARE PROVIDER #