Provider Demographics
NPI:1427740943
Name:FUDGE, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FUDGE
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 1:7132 260TH ST
Mailing Address - Street 2:
Mailing Address - City:GLEN OAKS
Mailing Address - State:NY
Mailing Address - Zip Code:11004-1151
Mailing Address - Country:US
Mailing Address - Phone:347-834-4090
Mailing Address - Fax:
Practice Address - Street 1:7132 260TH ST
Practice Address - Street 2:
Practice Address - City:GLEN OAKS
Practice Address - State:NY
Practice Address - Zip Code:11004-1151
Practice Address - Country:US
Practice Address - Phone:134-783-4409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist