Healthcare Provider Details

I. General information

NPI: 1982248514
Provider Name (Legal Business Name): JAINABA MBENGA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8609 2ND AVE STE 506B
SILVER SPRING MD
20910-3362
US

IV. Provider business mailing address

413 HIDDEN BROOK DR APT L
GLEN BURNIE MD
21061-5444
US

V. Phone/Fax

Practice location:
  • Phone: 240-398-3514
  • Fax:
Mailing address:
  • Phone: 240-603-2411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: