Provider Demographics
NPI:1326302605
Name:DUDLEY, JESSICA R (MS ED TOD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:MS ED TOD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8063 BAMM HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:NY
Mailing Address - Zip Code:13041-9137
Mailing Address - Country:US
Mailing Address - Phone:315-333-0227
Mailing Address - Fax:
Practice Address - Street 1:6575 KIRKVILLE RD
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9809
Practice Address - Country:US
Practice Address - Phone:315-701-5710
Practice Address - Fax:315-701-5711
Is Sole Proprietor?:No
Enumeration Date:2012-07-01
Last Update Date:2012-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY880263174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist