Healthcare Provider Details

I. General information

NPI: 1427181189
Provider Name (Legal Business Name): JENNIFER ANNE TUDOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 12/11/2022
Certification Date: 12/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 E CANAL DR
TURLOCK CA
95380-3936
US

IV. Provider business mailing address

1341 ALLMON DR
CLARKSVILLE TN
37042-7854
US

V. Phone/Fax

Practice location:
  • Phone: 209-669-2853
  • Fax:
Mailing address:
  • Phone: 209-380-0772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: