Healthcare Provider Details

I. General information

NPI: 1306338363
Provider Name (Legal Business Name): NURISHA SHAVON JACK CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NURISHA SHAVON ZENEBE CNM

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3903 WOODHAVEN LN
BOWIE MD
20715-1276
US

IV. Provider business mailing address

3903 WOODHAVEN LN
BOWIE MD
20715-1276
US

V. Phone/Fax

Practice location:
  • Phone: 202-380-6880
  • Fax:
Mailing address:
  • Phone: 202-380-6880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number0024177805
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberR191018
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: