Provider Demographics
NPI:1669875811
Name:HENDRICKSON, JENNA LEE
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:LEE
Last Name:HENDRICKSON
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 1:506 EVERETT PLACE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-0001
Mailing Address - Country:US
Mailing Address - Phone:513-519-1652
Mailing Address - Fax:
Practice Address - Street 1:1821 HILLANDALE RD STE 24A
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-2671
Practice Address - Country:US
Practice Address - Phone:435-591-9383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-02
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19299363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics