Provider Demographics
NPI:1508087206
Name:JEGEDE, IBUKUNOLA CHARLES (PHD)
Entity Type:Individual
Prefix:DR
First Name:IBUKUNOLA
Middle Name:CHARLES
Last Name:JEGEDE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17500 BURKE ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68118-2244
Mailing Address - Country:US
Mailing Address - Phone:402-401-3566
Mailing Address - Fax:
Practice Address - Street 1:17500 BURKE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68118-2244
Practice Address - Country:US
Practice Address - Phone:402-401-3566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE561103G00000X
NE8170101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1417045642Medicaid