Provider Demographics
NPI:1922791268
Name:DJOMOU, JACQUELINE IDA
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:IDA
Last Name:DJOMOU
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 1:11200 LOCKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-4551
Mailing Address - Country:US
Mailing Address - Phone:240-938-0314
Mailing Address - Fax:
Practice Address - Street 1:11200 LOCKWOOD DR
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-4551
Practice Address - Country:US
Practice Address - Phone:240-938-0314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-01
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 171M00000X
DCHHA200002704374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health
No374U00000XNursing Service Related ProvidersHome Health Aide