Provider Demographics
NPI:1891351649
Name:HENDERSON, JACOB (DPT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7121 NEWPORT AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-3924
Mailing Address - Country:US
Mailing Address - Phone:567-249-8709
Mailing Address - Fax:
Practice Address - Street 1:2106 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2402
Practice Address - Country:US
Practice Address - Phone:757-838-6678
Practice Address - Fax:757-838-8116
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23052127432251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic