Provider Demographics
NPI:1902319023
Name:HENDRICKS, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:923 FINDLAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-4148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 COURT ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-3932
Practice Address - Country:US
Practice Address - Phone:740-354-6685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-11
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH163464101YA0400X
OHPRS.00394175T00000X
OHQMHS101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health