Healthcare Provider Details

I. General information

NPI: 1265627319
Provider Name (Legal Business Name): JENNIFER LYNN HUDSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 07/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 HOPE DR 366 MEDICAL GROUP, WOMEN'S HEALTH
MOUNTAIN HOME A F B ID
83648-1057
US

IV. Provider business mailing address

90 HOPE DR 366 MEDICAL GROUP, WOMEN'S HEALTH
MOUNTAIN HOME A F B ID
83648-1057
US

V. Phone/Fax

Practice location:
  • Phone: 208-282-7567
  • Fax:
Mailing address:
  • Phone: 208-282-7567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number58-002420
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0102202319
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: