Provider Demographics
NPI:1164235644
Name:HENDERSON, JAKARA
Entity type:Individual
Prefix:
First Name:JAKARA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAKARA
Other - Middle Name:
Other - Last Name:MARDIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:608 S MCKINNEY ST
Mailing Address - Street 2:
Mailing Address - City:MEXIA
Mailing Address - State:TX
Mailing Address - Zip Code:76667-3644
Mailing Address - Country:US
Mailing Address - Phone:409-597-5673
Mailing Address - Fax:
Practice Address - Street 1:1610 S MALCOLM X BLVD STE 320
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75226-2100
Practice Address - Country:US
Practice Address - Phone:409-597-5673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-29
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty