Healthcare Provider Details

I. General information

NPI: 1619712585
Provider Name (Legal Business Name): JENNINGS UBADI MEKOBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 BETTY LN
EWING NJ
08628-1632
US

IV. Provider business mailing address

228 BETTY LN
EWING NJ
08628-1632
US

V. Phone/Fax

Practice location:
  • Phone: 862-205-7165
  • Fax:
Mailing address:
  • Phone: 862-205-7165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ01218000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: