Provider Demographics
NPI:1790451243
Name:OGBEIDE, JASON KPEMOSA
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:KPEMOSA
Last Name:OGBEIDE
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 1:3955 FAIRCROSS PL UNIT 77
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-6570
Mailing Address - Country:US
Mailing Address - Phone:213-436-0752
Mailing Address - Fax:
Practice Address - Street 1:3955 FAIRCROSS PL UNIT 77
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-6570
Practice Address - Country:US
Practice Address - Phone:213-436-0752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes102X00000XBehavioral Health & Social Service ProvidersPoetry TherapistGroup - Multi-Specialty