Healthcare Provider Details

I. General information

NPI: 1861091266
Provider Name (Legal Business Name): JONATHAN RYAN HUDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 AULT RD STE B
SIGNAL MOUNTAIN TN
37377-3126
US

IV. Provider business mailing address

PO BOX 93
SIGNAL MOUNTAIN TN
37377-0093
US

V. Phone/Fax

Practice location:
  • Phone: 423-822-8432
  • Fax:
Mailing address:
  • Phone: 423-521-5404
  • Fax: 706-406-2922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN242148
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0000027716
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: