Provider Demographics
NPI:1790443794
Name:HUDSON, JENNIFER LEEANN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEEANN
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 1:4208 SE 24TH ST
Mailing Address - Street 2:
Mailing Address - City:DEL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115-2529
Mailing Address - Country:US
Mailing Address - Phone:405-219-9011
Mailing Address - Fax:
Practice Address - Street 1:4208 SE 24TH ST
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-2529
Practice Address - Country:US
Practice Address - Phone:405-219-9011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1194701516175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist