Provider Demographics
NPI:1922234764
Name:HENRICKSON, SALLY JANE (RN/LCSW)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:JANE
Last Name:HENRICKSON
Suffix:
Gender:F
Credentials:RN/LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N TUCKER BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63101-1114
Mailing Address - Country:US
Mailing Address - Phone:314-802-1975
Mailing Address - Fax:314-802-1983
Practice Address - Street 1:800 N TUCKER BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63101-1114
Practice Address - Country:US
Practice Address - Phone:314-802-1975
Practice Address - Fax:314-802-1983
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO075944163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse