MEDICARE: MR. WILLIS JASON HUDSON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCS4463	CA

General Provider Information

NPI Number	:	1487972824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILLIS JASON HUDSON LCSW

Provider Business Mailing Address
First Line	:	2443 WASHINGTON AVE
Second Line	:
City	:	REDWOOD CITY
State	:	CA
Zip	:	94061-2523
Country	:	US
Telephone Number	:	559-349-6826
Fax Number	:	559-685-8953

Provider Business Practice Location Address
First Line	:	2443 WASHINGTON AVE
Second Line	:
City	:	REDWOOD CITY
State	:	CA
Zip	:	94061-2523
Country	:	US
Telephone Number	:	559-349-6826
Fax Number	:	559-685-8953

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2010
Last Update Date	:	05/10/2010

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