Healthcare Provider Details

I. General information

NPI: 1134484751
Provider Name (Legal Business Name): JAMIE LYNN HENDRICKS FNP-BC, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6825 HOVE RD
MELBA ID
83641-5201
US

IV. Provider business mailing address

6825 HOVE RD
MELBA ID
83641-5201
US

V. Phone/Fax

Practice location:
  • Phone: 616-610-5229
  • Fax:
Mailing address:
  • Phone: 616-610-5229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704248959
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: