Provider Demographics
NPI:1013363670
Name:OKONIGBO, JESSE (NP)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:OKONIGBO
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:JESSE
Other - Middle Name:
Other - Last Name:OKONIGBO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:10440 LITTLE PATUXENT PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-3648
Mailing Address - Country:US
Mailing Address - Phone:240-702-3574
Mailing Address - Fax:
Practice Address - Street 1:10440 LITTLE PATUXENT PKWY STE 300
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3648
Practice Address - Country:US
Practice Address - Phone:240-702-3574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-12
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR201977363LX0106X, 363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health