Provider Demographics
NPI:1184334815
Name:HENDRICKS, JON REED (PEER SPECIALIST)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:REED
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:PEER SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 ANDREWS AVE
Mailing Address - Street 2:
Mailing Address - City:WHEATLEY HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11798-2333
Mailing Address - Country:US
Mailing Address - Phone:516-229-1706
Mailing Address - Fax:
Practice Address - Street 1:45 ANDREWS AVE
Practice Address - Street 2:
Practice Address - City:WHEATLEY HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11798-2333
Practice Address - Country:US
Practice Address - Phone:516-229-1706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY780097405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional