Provider Demographics
NPI:1184331902
Name:FATAWU, JELYA INGRID (PMHMP-BC)
Entity type:Individual
Prefix:MS
First Name:JELYA
Middle Name:INGRID
Last Name:FATAWU
Suffix:
Gender:
Credentials:PMHMP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 LIBERTY GROVE CT
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-7188
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 LIBERTY GROVE CT
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-7188
Practice Address - Country:US
Practice Address - Phone:216-246-5697
Practice Address - Fax:314-216-3851
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-01
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022035166363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health