Provider Demographics
NPI:1912669441
Name:HUDSON, DEJANIQUE EDITH
Entity type:Individual
Prefix:
First Name:DEJANIQUE
Middle Name:EDITH
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 1:4892 SAN PABLO DAM RD
Mailing Address - Street 2:
Mailing Address - City:EL SOBRANTE
Mailing Address - State:CA
Mailing Address - Zip Code:94803-3222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1060 MANOR RD
Practice Address - Street 2:
Practice Address - City:EL SOBRANTE
Practice Address - State:CA
Practice Address - Zip Code:94803-1336
Practice Address - Country:US
Practice Address - Phone:510-236-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker