Healthcare Provider Details

I. General information

NPI: 1992668420
Provider Name (Legal Business Name): MRS. JESSICA UKANDU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 KINGS VALLEY DR
BOWIE MD
20721-1939
US

IV. Provider business mailing address

1403 KINGS VALLEY DR
BOWIE MD
20721-1939
US

V. Phone/Fax

Practice location:
  • Phone: 240-595-5259
  • Fax:
Mailing address:
  • Phone: 240-595-5259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR239978
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: