Provider Demographics
NPI:1033978655
Name:EJIM, JUDE CHIBUOGWU (NP)
Entity Type:Individual
Prefix:
First Name:JUDE
Middle Name:CHIBUOGWU
Last Name:EJIM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8150 N 61ST AVE APT 1073
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-6782
Mailing Address - Country:US
Mailing Address - Phone:225-485-6310
Mailing Address - Fax:
Practice Address - Street 1:2500 E VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-6037
Practice Address - Country:US
Practice Address - Phone:602-685-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ304136363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health