Provider Demographics
NPI:1972270130
Name:JUSU, MBAWA MONDEH
Entity Type:Individual
Prefix:
First Name:MBAWA
Middle Name:MONDEH
Last Name:JUSU
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 1:6323 GEORGIA AVE NW STE 305
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-1141
Mailing Address - Country:US
Mailing Address - Phone:301-434-3503
Mailing Address - Fax:
Practice Address - Street 1:6104 BREEZEWOOD DR APT 203
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-4158
Practice Address - Country:US
Practice Address - Phone:240-467-8408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA20001211374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide