Provider Demographics
NPI:1245630045
Name:HENDERSON, JENNIFER (DAOM, LAC)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:DAOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 CIVIC DR STE 111
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-8231
Mailing Address - Country:US
Mailing Address - Phone:925-457-2921
Mailing Address - Fax:
Practice Address - Street 1:1111 CIVIC DR STE 111
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-8231
Practice Address - Country:US
Practice Address - Phone:925-457-2921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-28
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 14663171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist