Provider Demographics
NPI:1154813400
Name:JACKSON HUDDLESTON, SONYA RENAE
Entity Type:Individual
Prefix:MS
First Name:SONYA
Middle Name:RENAE
Last Name:JACKSON HUDDLESTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2656 N BUFFALO DR UNIT 1306
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-4812
Mailing Address - Country:US
Mailing Address - Phone:702-808-3041
Mailing Address - Fax:888-725-8902
Practice Address - Street 1:2656 N BUFFALO DR UNIT 1306
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-4812
Practice Address - Country:US
Practice Address - Phone:702-808-3041
Practice Address - Fax:888-725-8902
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-02
Last Update Date:2018-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner