Healthcare Provider Details

I. General information

NPI: 1003875253
Provider Name (Legal Business Name): JACQUELYNN DIAN HENDERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 01/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 N 22ND ST
PHOENIX AZ
85016-4701
US

IV. Provider business mailing address

4800 N 22ND ST
PHOENIX AZ
85016-4701
US

V. Phone/Fax

Practice location:
  • Phone: 602-955-1000
  • Fax: 602-508-4830
Mailing address:
  • Phone: 602-955-1000
  • Fax: 602-508-4830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA13970
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5994
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: