Provider Demographics
NPI:1013363670
Name:OKONIGBO, JESSE (NP)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:OKONIGBO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:JESSE
Other - Middle Name:
Other - Last Name:OKONIGBO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:14280 BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-5006
Mailing Address - Country:US
Mailing Address - Phone:302-382-7248
Mailing Address - Fax:
Practice Address - Street 1:116 WARWICKSHIRE LN
Practice Address - Street 2:APT E
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-1727
Practice Address - Country:US
Practice Address - Phone:302-382-7248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-12
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR201977363LX0106X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health