Provider Demographics
NPI:1962733816
Name:JACKSON-HUDSON, ROLANDA YVETTE
Entity type:Individual
Prefix:
First Name:ROLANDA
Middle Name:YVETTE
Last Name:JACKSON-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:HHD/USAG-ADCO-ASAP
Mailing Address - Street 2:UNIT 15543
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96224-5543
Mailing Address - Country:US
Mailing Address - Phone:010-730-4172
Mailing Address - Fax:
Practice Address - Street 1:HHD USAG UNIT 15543 ADCO
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96224-5543
Practice Address - Country:US
Practice Address - Phone:010-730-4172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
5088OtherTRICARE