Healthcare Provider Details

I. General information

NPI: 1689661662
Provider Name (Legal Business Name): JERRY LUCAS HENDRIX P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 07/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

258 DALE HAVEN LN
TULLAHOMA TN
37388-8006
US

IV. Provider business mailing address

258 DALE HAVEN LN
TULLAHOMA TN
37388-8006
US

V. Phone/Fax

Practice location:
  • Phone: 931-581-8390
  • Fax:
Mailing address:
  • Phone: 931-581-8390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT0000007480
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number17409
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: