Healthcare Provider Details

I. General information

NPI: 1144737248
Provider Name (Legal Business Name): JENNIFER HENSON RN, CHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2018
Last Update Date: 01/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 STACEY BURK DR
FLORA IL
62839-3241
US

IV. Provider business mailing address

310 HICKORY ST
FLORA IL
62839-1068
US

V. Phone/Fax

Practice location:
  • Phone: 618-662-2191
  • Fax: 618-662-2191
Mailing address:
  • Phone: 618-919-0517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041349142
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: