Provider Demographics
NPI:1902212061
Name:BALOGUN, BOLUTIFE JENNIFER
Entity Type:Individual
Prefix:MS
First Name:BOLUTIFE
Middle Name:JENNIFER
Last Name:BALOGUN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 SAINT PAUL ST
Mailing Address - Street 2:APT 10R
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-2649
Mailing Address - Country:US
Mailing Address - Phone:631-897-2943
Mailing Address - Fax:
Practice Address - Street 1:1010 SAINT PAUL ST
Practice Address - Street 2:APT 10R
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2649
Practice Address - Country:US
Practice Address - Phone:631-897-2943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor