Healthcare Provider Details

I. General information

NPI: 1922459478
Provider Name (Legal Business Name): GABRIELLE LORRAINE HUDSON MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GABRIELLE LORRAINE JACKSON

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 E 120TH ST
LOS ANGELES CA
90059-3026
US

IV. Provider business mailing address

1319 CYPRESS AVE APT 3
LOS ANGELES CA
90065-1269
US

V. Phone/Fax

Practice location:
  • Phone: 424-338-8672
  • Fax: 424-338-8962
Mailing address:
  • Phone: 424-338-8672
  • Fax: 243-388-9624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW90242
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: