Provider Demographics
NPI:1184983744
Name:MBENGA, JEFFERSON (FNP)
Entity type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:
Last Name:MBENGA
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 NW 57TH ST STE 304
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-7070
Mailing Address - Country:US
Mailing Address - Phone:405-418-4777
Mailing Address - Fax:405-753-4515
Practice Address - Street 1:2828 NW 57TH ST STE 304
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-7070
Practice Address - Country:US
Practice Address - Phone:405-418-4777
Practice Address - Fax:405-745-4515
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-16
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK217427363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily