Provider Demographics
NPI:1891983151
Name:HENDERSON, JACK J (LPC)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:J
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1910 WESTMEAD DRIVE
Mailing Address - Street 2:3510
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-4724
Mailing Address - Country:US
Mailing Address - Phone:832-643-3256
Mailing Address - Fax:281-809-5854
Practice Address - Street 1:1910 WESTMEAD DRIVE
Practice Address - Street 2:3510
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77077-4724
Practice Address - Country:US
Practice Address - Phone:832-643-3256
Practice Address - Fax:281-809-5854
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11678101YP2500X
TX3334106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112950407Medicaid
TX112950407Medicaid
112950407OtherUNITED HEALTHCARE