Individual
JACQUELYNN DIAN HENDERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
4800 N 22ND ST, PHOENIX, AZ 85016-4701
(602) 955-1000
(602) 508-4830
Mailing address
4800 N 22ND ST, PHOENIX, AZ 85016-4701
(602) 955-1000
(602) 508-4830
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
5994
AZ
363A00000X
Physician Assistant
PA13970
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
Z181353
MEDICARE PTAN
AZ
Enumeration date
03/17/2006
Last updated
01/11/2016
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