Healthcare Provider Details

I. General information

NPI: 1477015196
Provider Name (Legal Business Name): JENNIFER MARIE HUDSON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JENNIFER HUDSON 201 INDEPENDENCE DRIVE
COLUMBUS AFB MS
39710
US

IV. Provider business mailing address

201 INDEPENDENCE
COLUMBUS MS
39710-5300
US

V. Phone/Fax

Practice location:
  • Phone: 662-434-2292
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4213C
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: