Provider Demographics
NPI:1245258623
Name:HUDSON, JENNIFER ROBIN (MPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROBIN
Last Name:HUDSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 E VIRGINIA WAY
Mailing Address - Street 2:SUITE N
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-3978
Mailing Address - Country:US
Mailing Address - Phone:760-256-9243
Mailing Address - Fax:760-256-4069
Practice Address - Street 1:705 E VIRGINIA WAY
Practice Address - Street 2:SUITE N
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-3978
Practice Address - Country:US
Practice Address - Phone:760-256-9243
Practice Address - Fax:760-256-4069
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23834225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGJ823YMedicare PIN
CAOPT238341Medicare PIN
CAW17215Medicare PIN
CAGJ823ZMedicare PIN
CAW17215AMedicare PIN