Healthcare Provider Details

I. General information

NPI: 1083575682
Provider Name (Legal Business Name): JACKSON NGANGA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2025
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 GLENWOOD AVE
BALTIMORE MD
21212-4230
US

IV. Provider business mailing address

8501 CASTLEMILL CIR
NOTTINGHAM MD
21236-2606
US

V. Phone/Fax

Practice location:
  • Phone: 410-323-9811
  • Fax: 410-323-3862
Mailing address:
  • Phone: 410-323-9811
  • Fax: 443-552-3232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP43242
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: