Provider Demographics
NPI:1033185699
Name:HENDRICKS, JONATHAN CLEON (PA-C)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:CLEON
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 MATIA DR
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-9539
Mailing Address - Country:US
Mailing Address - Phone:523-561-2513
Mailing Address - Fax:
Practice Address - Street 1:636 DEL PRADO BOULEVARD
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-2695
Practice Address - Country:US
Practice Address - Phone:239-424-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101920363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291231700Medicaid
FLE6929Medicare PIN
FL291231700Medicaid
FLP02525Medicare UPIN
FL970028146Medicare PIN