Provider Demographics
NPI:1326152232
Name:HUDSON, JACK G (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:G
Last Name:HUDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-261-1500
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:7148 U S HIGHWAY 98
Practice Address - Street 2:SUITE 101
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-8577
Practice Address - Country:US
Practice Address - Phone:601-261-1500
Practice Address - Fax:601-276-7549
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09620207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1558913OtherAMERICAN ADMIN GROUP
MS00019293Medicaid
010027374OtherRAILROAD MEDICARE
010027374OtherRAILROAD MEDICARE
B30690Medicare UPIN