Provider Demographics
NPI:1407429772
Name:JEGEDE, OLAOLU
Entity Type:Individual
Prefix:
First Name:OLAOLU
Middle Name:
Last Name:JEGEDE
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 1:2203 MONTAUK RD NW APT 4
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24017-1215
Mailing Address - Country:US
Mailing Address - Phone:503-860-7153
Mailing Address - Fax:
Practice Address - Street 1:4600 LENA DR
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17055-4904
Practice Address - Country:US
Practice Address - Phone:717-591-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9531332163WC3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC3500XNursing Service ProvidersRegistered NurseCardiac Rehabilitation