Provider Demographics
NPI:1861284572
Name:HUDSON, JACQUELYN KELLY
Entity type:Individual
Prefix:
First Name:JACQUELYN KELLY
Middle Name:
Last Name:HUDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5477 S. PICCADILLY CIRCLE
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-1446
Mailing Address - Country:US
Mailing Address - Phone:248-752-2077
Mailing Address - Fax:
Practice Address - Street 1:20549 STOUT ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-1428
Practice Address - Country:US
Practice Address - Phone:313-766-5846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-19
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIR312086310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility