Provider Demographics
NPI:1023618204
Name:HUDSON, JACOB (LPC)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
Last Name:HUDSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 WILBORN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-3120
Mailing Address - Country:US
Mailing Address - Phone:434-517-3653
Mailing Address - Fax:434-517-3043
Practice Address - Street 1:504 WILBORN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-3120
Practice Address - Country:US
Practice Address - Phone:434-517-3653
Practice Address - Fax:434-517-3043
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701010038101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional