Basic Information
| Provider Information | |||||||||
| NPI: | 1457304016 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDRICKSON | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2350 EAST BIDWELL ST | ||||||||
| Address2: | |||||||||
| City: | FOLSOM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956303455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169843899 | ||||||||
| FaxNumber: | 9169846522 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 E BIDWELL ST | ||||||||
| Address2: | |||||||||
| City: | FOLSOM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956303455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169843899 | ||||||||
| FaxNumber: | 9169846522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 11/19/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | G83722 | CA | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | G83722 | 01 | CA | LICENSE | OTHER |