Provider Demographics
NPI:1700897279
Name:HENDRICKSON, JOHN A (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:HENDRICKSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7206 W FREISTADT ROAD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-1018
Mailing Address - Country:US
Mailing Address - Phone:262-512-9977
Mailing Address - Fax:
Practice Address - Street 1:8911 NORTH PORT WASHINGTON ROAD
Practice Address - Street 2:SPORT CLINIC PHYSICAL THERAPY INC
Practice Address - City:BAYSIDE
Practice Address - State:WI
Practice Address - Zip Code:53217
Practice Address - Country:US
Practice Address - Phone:414-351-5794
Practice Address - Fax:414-351-2770
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1987024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40078100Medicaid
WI0000800590001Medicare ID - Type Unspecified
WI40078100Medicaid