Basic Information
Provider Information | |||||||||
NPI: | 1033366331 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENDERSON | ||||||||
FirstName: | JACQUELINE | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 110 E 42ND ST | ||||||||
Address2: | SUITE 1504 | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100175611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2123542622 | ||||||||
FaxNumber: | 2123542752 | ||||||||
Practice Location | |||||||||
Address1: | 110 E 42ND ST | ||||||||
Address2: | SUITE 1504 | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100175611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2123542622 | ||||||||
FaxNumber: | 2123542752 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/19/2008 | ||||||||
LastUpdateDate: | 11/10/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 033159 | NY | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.