Provider Demographics
NPI:1861414948
Name:HENDERSON, JERRY LYNN (PT)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LYNN
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17644 140TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:WOODINVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98072-6800
Mailing Address - Country:US
Mailing Address - Phone:425-402-9772
Mailing Address - Fax:425-402-9443
Practice Address - Street 1:17644 140TH AVE NE
Practice Address - Street 2:
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072-6800
Practice Address - Country:US
Practice Address - Phone:425-402-9772
Practice Address - Fax:425-402-9443
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002471225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA19038OtherL&I PIN#
WA7114150Medicaid
WA0160454OtherL&I GROUP #
WA8323677Medicaid
WAGAB29008Medicare ID - Type UnspecifiedGROUP NUMBER
WA7114150Medicaid