Healthcare Provider Details

I. General information

NPI: 1962406835
Provider Name (Legal Business Name): JACKSON MAINA NGANGA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 S OLD DIXIE HWY
JUPITER FL
33458-7205
US

IV. Provider business mailing address

1210 S OLD DIXIE HWY
JUPITER FL
33458-7205
US

V. Phone/Fax

Practice location:
  • Phone: 561-263-2234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME132336
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0053131
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number21137
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: