Provider Demographics
NPI:1336548155
Name:HUDSON, JENNIFER NICOLE (NP)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:NICOLE
Last Name:HUDSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:NICOLE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3732 NAMEOKI RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040
Practice Address - Country:US
Practice Address - Phone:314-221-0793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-18
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.416814164W00000X
246ZE0600X
MO2020041195363L00000X
IL209.017894363LF0000X
IL209017894363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily