Basic Information
| Provider Information | |||||||||
| NPI: | 1477015196 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUDSON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | LICSW, AADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 377TH MEDICAL GROUP 2050A 2ND ST SE | ||||||||
| Address2: | |||||||||
| City: | KIRTLAND AFB | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871170001 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | JENNIFER HUDSON 2050A 2ND ST SE | ||||||||
| Address2: | |||||||||
| City: | KIRTLAND AFB | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871170001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3349538607 | ||||||||
| FaxNumber: | 3349538607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2019 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | AADC-173 | AL | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 4213C | AL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.