Provider Demographics
NPI:1932225950
Name:HUDSON, JEAN ELLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:ELLEN
Last Name:HUDSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W WIEUCA RD NE
Mailing Address - Street 2:BUILDING 2, SUITE 200
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-3352
Mailing Address - Country:US
Mailing Address - Phone:404-303-8900
Mailing Address - Fax:
Practice Address - Street 1:300 W WIEUCA RD NE
Practice Address - Street 2:BUILDING 2, SUITE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-3352
Practice Address - Country:US
Practice Address - Phone:404-303-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1383103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00587221AMedicaid
R61620Medicare UPIN
GA00587221AMedicaid