Provider Demographics
NPI:1376066415
Name:ASSOGBA, JEANNINE (FNP, PMHNP)
Entity type:Individual
Prefix:
First Name:JEANNINE
Middle Name:
Last Name:ASSOGBA
Suffix:
Gender:F
Credentials:FNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3424 KOSSUTH AVE FL 11A-19
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2410
Mailing Address - Country:US
Mailing Address - Phone:718-519-3412
Mailing Address - Fax:
Practice Address - Street 1:3424 KOSSUTH AVE # 11A-19
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2410
Practice Address - Country:US
Practice Address - Phone:718-519-3412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-20
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340611363LF0000X
NY405118363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily