=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205189768
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSIE MARIE JUDKINS M. S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2012
-----------------------------------------------------
Last Update Date | 10/22/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 206 S PATTERSON ST
-----------------------------------------------------
City | VALDOSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31601-5668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-259-5138
-----------------------------------------------------
Fax | 229-245-6561
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1027
-----------------------------------------------------
City | VALDOSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31603-1027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-259-5138
-----------------------------------------------------
Fax | 229-245-6561
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------