1891983151 NPI number — MR. JACK J HENDERSON LPC

Table of content: MR. JACK J HENDERSON LPC (NPI 1891983151)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891983151 NPI number — MR. JACK J HENDERSON LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
JACK
Provider Middle Name:
J
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891983151
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1910 WESTMEAD DRIVE
Provider Second Line Business Practice Location Address:
3510
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77077-4724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-643-3256
Provider Business Practice Location Address Fax Number:
281-809-5854
Provider Enumeration Date:
10/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  11678 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 106H00000X , with the licence number: 3334 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 112950407 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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