MEDICARE: MRS. NICOLEA ALICIA HUDSON-JACK AAS

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	224Z00000X	Occupational Therapy Assistant	004266	NY

General Provider Information

NPI Number	:	1598533200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NICOLEA ALICIA HUDSON-JACK AAS

Provider Business Mailing Address
First Line	:	12952 135TH ST
Second Line	:
City	:	SOUTH OZONE PARK
State	:	NY
Zip	:	11420-3542
Country	:	US
Telephone Number	:	917-941-8617
Fax Number	:

Provider Business Practice Location Address
First Line	:	12952 135TH ST
Second Line	:
City	:	SOUTH OZONE PARK
State	:	NY
Zip	:	11420-3542
Country	:	US
Telephone Number	:	917-941-8617
Fax Number	:

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

Provider Enumeration Date	:	12/13/2023
Last Update Date	:	12/13/2023

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