Provider Demographics
NPI:1598533200
Name:HUDSON-JACK, NICOLEA ALICIA (AAS)
Entity Type:Individual
Prefix:MRS
First Name:NICOLEA
Middle Name:ALICIA
Last Name:HUDSON-JACK
Suffix:
Gender:F
Credentials:AAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12952 135TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-3542
Mailing Address - Country:US
Mailing Address - Phone:917-941-8617
Mailing Address - Fax:
Practice Address - Street 1:12952 135TH ST
Practice Address - Street 2:
Practice Address - City:SOUTH OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420-3542
Practice Address - Country:US
Practice Address - Phone:917-941-8617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004266224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant