Provider Demographics
NPI:1407508799
Name:JOSE, TOKUNBO JIMMY
Entity Type:Individual
Prefix:
First Name:TOKUNBO
Middle Name:JIMMY
Last Name:JOSE
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 1:41B W MERRICK RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-5756
Mailing Address - Country:US
Mailing Address - Phone:516-459-2920
Mailing Address - Fax:
Practice Address - Street 1:41B W MERRICK RD
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-5756
Practice Address - Country:US
Practice Address - Phone:516-459-2920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP113600101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health