Provider Demographics
NPI:1689103905
Name:HENDERSON, JONATHAN (PT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
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 1:4789 ELLENDALE RD
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38135-1105
Mailing Address - Country:US
Mailing Address - Phone:901-359-2569
Mailing Address - Fax:
Practice Address - Street 1:7895 STAGE HILLS BLVD STE 107
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38133-4049
Practice Address - Country:US
Practice Address - Phone:901-590-2379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8816225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist