Provider Demographics
NPI:1891072567
Name:HENDRICKSON, JASON L (RPH)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:L
Last Name:HENDRICKSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12475 TAMA RUN LN
Mailing Address - Street 2:
Mailing Address - City:DARLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53530-9649
Mailing Address - Country:US
Mailing Address - Phone:608-776-2403
Mailing Address - Fax:
Practice Address - Street 1:675 S WATER ST
Practice Address - Street 2:
Practice Address - City:PLATTEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53818-3608
Practice Address - Country:US
Practice Address - Phone:608-348-7611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13095-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist