Provider Demographics
NPI:1295226140
Name:DUDDLESTON, JESSICA ARNOLD (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:ARNOLD
Last Name:DUDDLESTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3928 MONTCLAIR RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN BRK
Mailing Address - State:AL
Mailing Address - Zip Code:35213-2415
Mailing Address - Country:US
Mailing Address - Phone:205-592-3911
Mailing Address - Fax:
Practice Address - Street 1:3928 MONTCLAIR RD STE 100
Practice Address - Street 2:
Practice Address - City:MOUNTAIN BRK
Practice Address - State:AL
Practice Address - Zip Code:35213-2415
Practice Address - Country:US
Practice Address - Phone:205-592-3911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-27
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL44247207W00000X
NC238534390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCPE-62FZXC0QWMedicaid