Healthcare Provider Details

I. General information

NPI: 1699296038
Provider Name (Legal Business Name): JARED HENDERSHOT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 LAURENCE AVE
JACKSON MI
49202
US

IV. Provider business mailing address

4370 CHICAGO DR SW STE 735
GRANDVILLE MI
49418-1694
US

V. Phone/Fax

Practice location:
  • Phone: 517-750-4777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: