Provider Demographics
NPI:1407642689
Name:HENDERSON, AMANDA JAQUAY
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JAQUAY
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2608 BRIAR ROSE CT
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-1582
Mailing Address - Country:US
Mailing Address - Phone:409-996-1351
Mailing Address - Fax:
Practice Address - Street 1:10707 CORPORATE DR STE 140
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-4092
Practice Address - Country:US
Practice Address - Phone:409-996-1351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-16
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1193342363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily