Healthcare Provider Details

I. General information

NPI: 1326615543
Provider Name (Legal Business Name): CRYSTAL HUDKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 JOHNSON ST STE C
JENNINGS LA
70546-3650
US

IV. Provider business mailing address

15137 COUNTY LANE 220
JASPER MO
64755-8270
US

V. Phone/Fax

Practice location:
  • Phone: 337-616-0225
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: