Provider Demographics
NPI:1265627319
Name:HUDSON, JENNIFER LYNN (DO)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:HUDSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:90 HOPE DR
Mailing Address - Street 2:366 MEDICAL GROUP, WOMEN'S HEALTH
Mailing Address - City:MOUNTAIN HOME A F B
Mailing Address - State:ID
Mailing Address - Zip Code:83648-1057
Mailing Address - Country:US
Mailing Address - Phone:208-282-7567
Mailing Address - Fax:
Practice Address - Street 1:90 HOPE DR
Practice Address - Street 2:366 MEDICAL GROUP, WOMEN'S HEALTH
Practice Address - City:MOUNTAIN HOME A F B
Practice Address - State:ID
Practice Address - Zip Code:83648-1057
Practice Address - Country:US
Practice Address - Phone:208-282-7567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58-002420207V00000X
VA0102202319207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology