Provider Demographics
NPI:1386876746
Name:JUDD, NATHAN (MS)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:JUDD
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1385
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-1385
Mailing Address - Country:US
Mailing Address - Phone:731-988-5251
Mailing Address - Fax:731-427-5605
Practice Address - Street 1:3641 YOUTH TOWN RD
Practice Address - Street 2:
Practice Address - City:PINSON
Practice Address - State:TN
Practice Address - Zip Code:38366-9804
Practice Address - Country:US
Practice Address - Phone:731-988-5251
Practice Address - Fax:731-427-5605
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-19
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
TN2832101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1527990Medicaid