Provider Demographics
NPI:1467200923
Name:HENDERSON, JUSTICE KERISSA
Entity type:Individual
Prefix:
First Name:JUSTICE
Middle Name:KERISSA
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 1:10816 CORY ST
Mailing Address - Street 2:
Mailing Address - City:MANVEL
Mailing Address - State:TX
Mailing Address - Zip Code:77578-5544
Mailing Address - Country:US
Mailing Address - Phone:832-812-0810
Mailing Address - Fax:
Practice Address - Street 1:10816 CORY ST
Practice Address - Street 2:
Practice Address - City:MANVEL
Practice Address - State:TX
Practice Address - Zip Code:77578-5544
Practice Address - Country:US
Practice Address - Phone:832-812-0810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390175042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty