Provider Demographics
NPI:1235480864
Name:MBOUWETASSI, JEANNETTE
Entity Type:Individual
Prefix:MS
First Name:JEANNETTE
Middle Name:
Last Name:MBOUWETASSI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11342 CHERRY HILL RD UNIT 201
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-3735
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:39 PEABODY ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-1546
Practice Address - Country:US
Practice Address - Phone:202-726-9707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-22
Last Update Date:2012-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide