Provider Demographics
NPI:1922244904
Name:DUDLEY, ROXANNE D (RN, PMHNP-BC, LPC)
Entity Type:Individual
Prefix:MS
First Name:ROXANNE
Middle Name:D
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:RN, PMHNP-BC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-3307
Mailing Address - Country:US
Mailing Address - Phone:512-573-8026
Mailing Address - Fax:
Practice Address - Street 1:1011 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-3307
Practice Address - Country:US
Practice Address - Phone:903-589-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62107101Y00000X
TXAP134786363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1268237-08Medicaid