=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063676062
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER LEIGH HENDRICKS PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2008
-----------------------------------------------------
Last Update Date | 03/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9055 SPRINGBROOK DR NW
-----------------------------------------------------
City | COON RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55433-5841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-780-6580
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11371 ELDORADO ST NE UNIT D
-----------------------------------------------------
City | BLAINE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55449-4550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-464-8610
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 10504
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------