Provider Demographics
NPI:1144671082
Name:HUDSON, JESSICA ANNE (DO)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:HUDSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22250 PROVIDENCE DR
Mailing Address - Street 2:STE. 500
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4825
Mailing Address - Country:US
Mailing Address - Phone:248-849-3441
Mailing Address - Fax:248-849-5386
Practice Address - Street 1:22250 PROVIDENCE DR
Practice Address - Street 2:STE. 500
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4825
Practice Address - Country:US
Practice Address - Phone:248-849-3441
Practice Address - Fax:248-849-5386
Is Sole Proprietor?:No
Enumeration Date:2016-06-22
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101024622207Q00000X
MI5101022524390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program