Provider Demographics
NPI:1295789584
Name:HENDERSON, JEFFERY LEONARD (PA-C)
Entity type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:LEONARD
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 E A AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:KS
Mailing Address - Zip Code:67068-1723
Mailing Address - Country:US
Mailing Address - Phone:620-532-5145
Mailing Address - Fax:620-532-2586
Practice Address - Street 1:701 E A AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:KS
Practice Address - Zip Code:67068-1723
Practice Address - Country:US
Practice Address - Phone:620-532-5145
Practice Address - Fax:620-532-2586
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00238363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical