Provider Demographics
NPI:1750886206
Name:HENRIQUEZ, JONATHAN (DC)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:HENRIQUEZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 FLORAL SPRINGS BLVD UNIT 12306
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-6806
Mailing Address - Country:US
Mailing Address - Phone:305-609-0271
Mailing Address - Fax:
Practice Address - Street 1:851 DUNLAWTON AVE STE 104
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4234
Practice Address - Country:US
Practice Address - Phone:386-366-7418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH12453111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor