Provider Demographics
NPI:1821352634
Name:JIMOH, ADAM (PMHNP)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:
Last Name:JIMOH
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 COMMODORE TER
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020-1184
Mailing Address - Country:US
Mailing Address - Phone:732-423-7396
Mailing Address - Fax:
Practice Address - Street 1:303 COMMODORE TER
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:07020-1184
Practice Address - Country:US
Practice Address - Phone:732-423-7396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR13614400163W00000X
NY405462363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0023701OtherAGENCY MEDICAID PROVIDER #