Provider Demographics
NPI:1467264515
Name:NGWA, JACKSON NJI FONLON TANIFORM
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:NJI FONLON TANIFORM
Last Name:NGWA
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 1:5221 CAPITOL HEIGHTS
Mailing Address - Street 2:
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743
Mailing Address - Country:US
Mailing Address - Phone:913-494-2143
Mailing Address - Fax:
Practice Address - Street 1:5221 CAPITOL HEIGHTS
Practice Address - Street 2:
Practice Address - City:CAPITOL HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20743
Practice Address - Country:US
Practice Address - Phone:913-494-2143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-24
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator