Provider Demographics
NPI:1154047587
Name:HUDSON, JACLYN (OTR)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:HUDSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 HUNT RD
Mailing Address - Street 2:
Mailing Address - City:FORT LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66027-1406
Mailing Address - Country:US
Mailing Address - Phone:719-352-1406
Mailing Address - Fax:
Practice Address - Street 1:721 METROPOLITAN AVE STE C
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-1403
Practice Address - Country:US
Practice Address - Phone:913-250-5452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS480015225X00000X
KS17-04080225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist