Provider Demographics
NPI:1386990901
Name:HUDSON, JEAN MARY (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:JEAN
Middle Name:MARY
Last Name:HUDSON
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 SANOK DR
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL HALL
Mailing Address - State:NY
Mailing Address - Zip Code:10916-2431
Mailing Address - Country:US
Mailing Address - Phone:845-496-2104
Mailing Address - Fax:
Practice Address - Street 1:124 MAIN ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-2124
Practice Address - Country:US
Practice Address - Phone:845-291-2332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY154844207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00473074Medicaid
NY00473074Medicaid