Healthcare Provider Details

I. General information

NPI: 1720040116
Provider Name (Legal Business Name): JAN HODGES HENDERSON PT,MS,PCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 04/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR NAVAL MEDICAL CENTER - PEDIATRICS
PORTSMOUTH VA
23708-2111
US

IV. Provider business mailing address

1640 CLARKS CIR
CHESAPEAKE VA
23321-6614
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-5165
  • Fax: 757-953-7134
Mailing address:
  • Phone: 757-966-1631
  • Fax: 757-953-7134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number2305002264
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: