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NPI Code Detail

MEDICARE: JAELANI DESERAE HENDERSON

MEDICARE: JAELANI DESERAE 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
1101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1659983112
Entity Type Code : Individual
Provider Name (Legal Business Name) : JAELANI DESERAE HENDERSON
Provider Business Mailing Address
First Line : 157 CRAWFORD ST APT 2
Second Line :
City : BOSTON
State : MA
Zip : 02121-1017
Country : US
Telephone Number : 617-322-4046
Fax Number :
Provider Business Practice Location Address
First Line : 192 THROOP AVE
Second Line :
City : BROOKLYN
State : NY
Zip : 11206-5334
Country : US
Telephone Number : 929-210-9333
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/17/2020
Last Update Date : 08/17/2020

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Directions to “ JAELANI DESERAE HENDERSON ” Practice Location

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