Healthcare Provider Details

I. General information

NPI: 1447210448
Provider Name (Legal Business Name): JON R HENDRICKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7303 ROGERS AVE
FORT SMITH AR
72903-4112
US

IV. Provider business mailing address

PO BOX 11017
FORT SMITH AR
72917-1017
US

V. Phone/Fax

Practice location:
  • Phone: 479-478-7200
  • Fax: 479-478-7225
Mailing address:
  • Phone: 479-478-7200
  • Fax: 478-478-7225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberN7630
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: