Healthcare Provider Details

I. General information

NPI: 1205710217
Provider Name (Legal Business Name): JEREMIAH OGAH PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2025
Last Update Date: 08/04/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 GRANITE ST
LYNN MA
01904-2915
US

IV. Provider business mailing address

60 GRANITE ST
LYNN MA
01904-2915
US

V. Phone/Fax

Practice location:
  • Phone: 781-599-9200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2346548
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: