=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902498462
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IJKL SERVICES INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2021
-----------------------------------------------------
Last Update Date | 11/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8600 LASALLE RD STE 321
-----------------------------------------------------
City | TOWSON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21286-2011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-985-0391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 TOKAY CT
-----------------------------------------------------
City | RANDALLSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21133-3729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-985-0391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JUSTINA UGORJI
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 443-985-0391
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------