Provider Demographics
NPI:1659013332
Name:IBRAHIM, SURAT JUMOKE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:SURAT
Middle Name:JUMOKE
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6814 BIG BEND LN
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76002-3510
Mailing Address - Country:US
Mailing Address - Phone:817-374-5640
Mailing Address - Fax:
Practice Address - Street 1:201 BILLINGS ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76010-5401
Practice Address - Country:US
Practice Address - Phone:817-803-4770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1071834363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health