Provider Demographics
NPI:1114504552
Name:ODUKOYA, JEREMIAH BABATUNDE
Entity Type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:BABATUNDE
Last Name:ODUKOYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16308 DAHL RD
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-2706
Mailing Address - Country:US
Mailing Address - Phone:804-385-7476
Mailing Address - Fax:
Practice Address - Street 1:1807 E PRESTON ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21213-3131
Practice Address - Country:US
Practice Address - Phone:410-276-2123
Practice Address - Fax:410-276-4070
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD263781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical