Provider Demographics
NPI:1861662751
Name:HENDRIX, KEITH JACOB (LPC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:JACOB
Last Name:HENDRIX
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53501 BROOKIE WAY
Mailing Address - Street 2:
Mailing Address - City:LA PINE
Mailing Address - State:OR
Mailing Address - Zip Code:97739-9440
Mailing Address - Country:US
Mailing Address - Phone:503-616-1236
Mailing Address - Fax:855-305-5252
Practice Address - Street 1:45 NW GREELEY AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2943
Practice Address - Country:US
Practice Address - Phone:503-616-1236
Practice Address - Fax:855-305-5252
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-06
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1799101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR123190Medicaid