MEDICARE: JESSICA A. HENDERSON PC

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	122300000X	Dentist		OR

General Provider Information

NPI Number	:	1720511173
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JESSICA A. HENDERSON PC

Provider Business Mailing Address
First Line	:	55110 JACK PINE WAY
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97707-2712
Country	:	US
Telephone Number	:	407-247-1497
Fax Number	:

Provider Business Practice Location Address
First Line	:	1016 NW NEWPORT AVE
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97703-1618
Country	:	US
Telephone Number	:	541-389-1107
Fax Number	:	541-317-5958

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	DR. JESSICA ANN HENDERSON
Credential	:	D.M.D.
Telephone Number	:	407-247-1497

Provider Enumeration Date	:	04/04/2017
Last Update Date	:	04/04/2017

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