Healthcare Provider Details

I. General information

NPI: 1508087206
Provider Name (Legal Business Name): IBUKUNOLA CHARLES JEGEDE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 11/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17500 BURKE ST
OMAHA NE
68118-2244
US

IV. Provider business mailing address

17500 BURKE ST
OMAHA NE
68118-2244
US

V. Phone/Fax

Practice location:
  • Phone: 402-401-3566
  • Fax:
Mailing address:
  • Phone: 402-401-3566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number561
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: