=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437916434
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J&T FUNCTIONAL MEDICINE AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2024
-----------------------------------------------------
Last Update Date | 03/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 LIBERTY PL
-----------------------------------------------------
City | SICKLERVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08081-5715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-456-3399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 LIBERTY PL
-----------------------------------------------------
City | SICKLERVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08081-5715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-456-3399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JACOB NWOSU
-----------------------------------------------------
Credential | DMSC-PA-C
-----------------------------------------------------
Telephone | 908-456-3399
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------