Provider Demographics
NPI:1851953962
Name:HUDGENS, JAMIE GRESHAWN (CPSS)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:GRESHAWN
Last Name:HUDGENS
Suffix:
Gender:F
Credentials:CPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1734 RIDGE CT SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-1726
Mailing Address - Country:US
Mailing Address - Phone:704-430-1117
Mailing Address - Fax:
Practice Address - Street 1:1734 RIDGE CT SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-1726
Practice Address - Country:US
Practice Address - Phone:704-430-1117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2018-5322-01175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2018-5322-01OtherPEER SUPPORT