Provider Demographics
NPI:1538142682
Name:HUDSON, JACQUELINE COLEEN (PA-C, MHS, BSN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:COLEEN
Last Name:HUDSON
Suffix:
Gender:F
Credentials:PA-C, MHS, BSN
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:COLEEN
Other - Last Name:HJELMSTAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C, MHS
Mailing Address - Street 1:3001 TRAILHEAD DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-0831
Mailing Address - Country:US
Mailing Address - Phone:701-340-4776
Mailing Address - Fax:
Practice Address - Street 1:1101 NW 178TH ST STE B
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73012-4281
Practice Address - Country:US
Practice Address - Phone:054-285-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2145363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant