MEDICARE: MR. JACK J HENDERSON LPC

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	101YP2500X	Professional Counselor	11678	TX
2	106H00000X	Marriage & Family Therapist	3334	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891983151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACK J HENDERSON LPC

Provider Business Mailing Address
First Line	:	1910 WESTMEAD DRIVE
Second Line	:	3510
City	:	HOUSTON
State	:	TX
Zip	:	77077-4724
Country	:	US
Telephone Number	:	832-643-3256
Fax Number	:	281-809-5854

Provider Business Practice Location Address
First Line	:	1910 WESTMEAD DRIVE
Second Line	:	3510
City	:	HOUSTON
State	:	TX
Zip	:	77077-4724
Country	:	US
Telephone Number	:	832-643-3256
Fax Number	:	281-809-5854

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

Provider Enumeration Date	:	10/11/2007
Last Update Date	:	10/10/2014

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