MEDICARE: MRS. JACQUELINE SUZANNE HENDRICKSON

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	261QM0850X	Adult Mental Health Clinic/Center	13683	CO
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center	13683	CO

General Provider Information

NPI Number	:	1912248394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JACQUELINE SUZANNE HENDRICKSON

Provider Business Mailing Address
First Line	:	1740 S COLLEGE AVE
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-1009
Country	:	US
Telephone Number	:	970-472-1207
Fax Number	:

Provider Business Practice Location Address
First Line	:	1740 S COLLEGE AVE
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-1009
Country	:	US
Telephone Number	:	970-472-1207
Fax Number	:

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

Provider Enumeration Date	:	03/08/2013
Last Update Date	:	05/31/2013

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