Provider Demographics
NPI:1689296345
Name:HUDSON, JADA ASHLEY
Entity Type:Individual
Prefix:
First Name:JADA
Middle Name:ASHLEY
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 1:222 E MIDDLE COUNTRY RD STE 310
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2814
Mailing Address - Country:US
Mailing Address - Phone:631-265-1622
Mailing Address - Fax:
Practice Address - Street 1:222 E MIDDLE COUNTRY RD STE 310
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2814
Practice Address - Country:US
Practice Address - Phone:631-265-1622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-15
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY758871163W00000X
NYF402989-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse