Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | 5201001619 |
NPI | 1023512894 |
---|---|
Provider Name | Jackie Lynn Hudson |
First Address | Zeeland, MI 49464-2608 |
Second Address | Zeeland, MI 49464-2608 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/03/2018 |
Last Update Date | 16/06/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5201001619 | (05) | MI |