Provider Demographics
NPI:1669227161
Name:UKPEBOR, JUDE OSAGIE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JUDE
Middle Name:OSAGIE
Last Name:UKPEBOR
Suffix:
Gender:M
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 1:27200 LAHSER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-2137
Mailing Address - Country:US
Mailing Address - Phone:248-208-9215
Mailing Address - Fax:248-208-9217
Practice Address - Street 1:27200 LAHSER RD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-2137
Practice Address - Country:US
Practice Address - Phone:248-208-9215
Practice Address - Fax:248-208-9217
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704363555363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty