MEDICARE: JONTAE HENDERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376K00000X	Nurse's Aide	401790980915	OH

General Provider Information

NPI Number	:	1386342632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONTAE HENDERSON

Provider Business Mailing Address
First Line	:	1115 E 177TH ST UNIT 1
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44119-3143
Country	:	US
Telephone Number	:	216-450-7939
Fax Number	:

Provider Business Practice Location Address
First Line	:	1115 E 177TH ST UNIT 1
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44119-3143
Country	:	US
Telephone Number	:	216-450-7939
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/16/2023
Last Update Date	:	06/14/2023

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Directions to “ JONTAE HENDERSON ” Practice Location

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