Healthcare Provider Details

I. General information

NPI: 1649091737
Provider Name (Legal Business Name): JABARI MOYENDA OSAZE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 10/21/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 MILWAUKEE AVE
DETROIT MI
48202
US

IV. Provider business mailing address

707 MILWAUKEE AVE
DETROIT MI
48202
US

V. Phone/Fax

Practice location:
  • Phone: 313-989-9444
  • Fax:
Mailing address:
  • Phone: 313-989-9444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number4704149257
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: