Provider Demographics
NPI:1700535630
Name:HUDSON, JONATHAN (CSFA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:HUDSON
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 S FLEISHEL AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2041
Mailing Address - Country:US
Mailing Address - Phone:903-606-5560
Mailing Address - Fax:
Practice Address - Street 1:630 S FLEISHEL AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2041
Practice Address - Country:US
Practice Address - Phone:903-606-5560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225500000X
TX208501246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist