Healthcare Provider Details

I. General information

NPI: 1336548155
Provider Name (Legal Business Name): JENNIFER NICOLE HUDSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER NICOLE WHITE NP

II. Dates (important events)

Enumeration Date: 08/18/2014
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3732 NAMEOKI RD
GRANITE CITY IL
62040
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-5534
US

V. Phone/Fax

Practice location:
  • Phone: 314-221-0793
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number041.416814
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2020041195
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.017894
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209017894
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: