MEDICARE: JAY A HENDRICKSON M.D.

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	208VP0014X	Interventional Pain Medicine Physician	G83722	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G83722	OTHER	CA	LICENSE

General Provider Information

NPI Number	:	1457304016
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAY A HENDRICKSON M.D.

Provider Business Mailing Address
First Line	:	2350 EAST BIDWELL ST
Second Line	:
City	:	FOLSOM
State	:	CA
Zip	:	95630-3455
Country	:	US
Telephone Number	:	916-984-3899
Fax Number	:	916-984-6522

Provider Business Practice Location Address
First Line	:	729 SUNRISE AVE STE 602
Second Line	:
City	:	ROSEVILLE
State	:	CA
Zip	:	95661-4542
Country	:	US
Telephone Number	:	916-953-7571
Fax Number	:	916-771-8515

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

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	12/12/2023

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