Provider Demographics
NPI:1972368462
Name:NWOSU, JAMES LUCKY
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:LUCKY
Last Name:NWOSU
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 1:5415 SW WESTGATE DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3513
Practice Address - Country:US
Practice Address - Phone:832-955-2409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR103T00000X103T00000X
OR225XM0800X225XM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist