Provider Demographics
NPI:1396416418
Name:HUDSON, JENNA ABIGAIL ROOSEVELT
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:ABIGAIL ROOSEVELT
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 1:105 FARWELL ST APT A
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02460-1029
Mailing Address - Country:US
Mailing Address - Phone:207-266-9974
Mailing Address - Fax:
Practice Address - Street 1:95 EASTERN AVE STE 8
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-4582
Practice Address - Country:US
Practice Address - Phone:617-996-1210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
MA1-25-78857103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician