Provider Demographics
NPI:1447858683
Name:HUDSON, JAZMINE
Entity type:Individual
Prefix:
First Name:JAZMINE
Middle Name:
Last Name:HUDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2551 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1798
Mailing Address - Country:US
Mailing Address - Phone:310-946-2039
Mailing Address - Fax:
Practice Address - Street 1:2551 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1798
Practice Address - Country:US
Practice Address - Phone:310-946-2039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-10
Last Update Date:2020-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies