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General NPI Number Information
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NPI Number | 1053872721
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Entity Type | Individual
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Provider Name | JESSICA D HENDERSON LCSW
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Gender | Female
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Dates
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Enumeration Date | 03/26/2019
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Last Update Date | 10/06/2023
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Provider Practice Location Address
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Address Line | 444 W FORT ST FL 2
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City | BOISE
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State | ID
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Zip | 83702-4535
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Country | US
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Telephone | 208-422-1018
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Fax |
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Provider Business Mailing Address
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Address Line | 3944 NE 15TH AVE
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City | PORTLAND
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State | OR
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Zip | 97212-1321
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Country | US
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Telephone | 919-280-9880
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | L7552
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License Number State | OR
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