Provider Demographics
NPI:1639540149
Name:HUDSON, JACOLYN
Entity Type:Individual
Prefix:
First Name:JACOLYN
Middle Name:
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:PO BOX 1114
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-1114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2213 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-2811
Practice Address - Country:US
Practice Address - Phone:503-982-4200
Practice Address - Fax:503-981-2323
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2019-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR348446225X00000X, 225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500647838Medicaid