Healthcare Provider Details

I. General information

NPI: 1093513582
Provider Name (Legal Business Name): JASON TYLER HENDRICKS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2025
Last Update Date: 03/02/2026
Certification Date: 03/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR UNIT MEDDAC
FT CARSON CO
80913-4604
US

IV. Provider business mailing address

840 SWIFT CT
COLORADO SPRINGS CO
80910-4312
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-7000
  • Fax:
Mailing address:
  • Phone: 717-606-9598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0009729
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: