Provider Demographics
NPI:1235889239
Name:MAJEKODUMI, JESSY A
Entity Type:Individual
Prefix:
First Name:JESSY
Middle Name:A
Last Name:MAJEKODUMI
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 1:15200 MEMORIAL DR UNIT 3212
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079-2658
Mailing Address - Country:US
Mailing Address - Phone:512-779-7545
Mailing Address - Fax:
Practice Address - Street 1:1515 HOLOCOMBE BLVDQ
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-7703
Practice Address - Country:US
Practice Address - Phone:713-745-6947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX139313367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX278904Medicaid