Provider Demographics
NPI:1912162116
Name:HENDERSON, JONATHAN FREDERICK (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:FREDERICK
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 GENESEE STREET
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413
Mailing Address - Country:US
Mailing Address - Phone:315-732-7909
Mailing Address - Fax:315-793-9307
Practice Address - Street 1:86 GENESEE STREET
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413
Practice Address - Country:US
Practice Address - Phone:315-732-7909
Practice Address - Fax:315-793-9307
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY257347208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03272199Medicaid