Provider Demographics
NPI:1629616743
Name:HUDSON, KADIJA YVETTE
Entity Type:Individual
Prefix:
First Name:KADIJA
Middle Name:YVETTE
Last Name:HUDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2404 FERRAND ST STE 23
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3233
Mailing Address - Country:US
Mailing Address - Phone:318-323-0463
Mailing Address - Fax:318-323-0465
Practice Address - Street 1:2404 FERRAND ST STE 23
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3233
Practice Address - Country:US
Practice Address - Phone:318-323-0463
Practice Address - Fax:318-323-0465
Is Sole Proprietor?:No
Enumeration Date:2019-12-19
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4701066Medicaid