Provider Demographics
NPI:1750449799
Name:FUDGE, JERRI
Entity Type:Individual
Prefix:
First Name:JERRI
Middle Name:
Last Name:FUDGE
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 1:1400 SUDDERTH DR
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-6103
Mailing Address - Country:US
Mailing Address - Phone:505-257-2368
Mailing Address - Fax:505-257-2141
Practice Address - Street 1:1400 SUDDERTH DR
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6103
Practice Address - Country:US
Practice Address - Phone:505-257-2368
Practice Address - Fax:505-257-2141
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM117235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist