Basic Information
| Provider Information | |||||||||
| NPI: | 1144671082 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUDSON | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22250 PROVIDENCE DR | ||||||||
| Address2: | STE. 500 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480754825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488493441 | ||||||||
| FaxNumber: | 2488495386 | ||||||||
| Practice Location | |||||||||
| Address1: | 22250 PROVIDENCE DR | ||||||||
| Address2: | STE. 500 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480754825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488493441 | ||||||||
| FaxNumber: | 2488495386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2016 | ||||||||
| LastUpdateDate: | 05/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101024622 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | 5101022524 | MI | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.