Provider Demographics
NPI:1912248394
Name:HENDRICKSON, JACQUELINE SUZANNE
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:SUZANNE
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:1740 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-1009
Mailing Address - Country:US
Mailing Address - Phone:970-472-1207
Mailing Address - Fax:
Practice Address - Street 1:1740 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-1009
Practice Address - Country:US
Practice Address - Phone:970-472-1207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-08
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13683261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health