Provider Demographics
NPI:1457666976
Name:RUDD, JEDEDIAH CHESTON (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:JEDEDIAH
Middle Name:CHESTON
Last Name:RUDD
Suffix:
Gender:M
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4134 N BLACKHAWK RD
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-6037
Mailing Address - Country:US
Mailing Address - Phone:575-574-8212
Mailing Address - Fax:
Practice Address - Street 1:4134 N BLACKHAWK RD
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-6037
Practice Address - Country:US
Practice Address - Phone:575-574-8212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2626225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist