Provider Demographics
NPI:1912257387
Name:DJEUTCHA, JEAN ROGER FODJA
Entity Type:Individual
Prefix:MR
First Name:JEAN ROGER
Middle Name:FODJA
Last Name:DJEUTCHA
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 1:506 CHILLUM RD APT 102
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20783
Mailing Address - Country:US
Mailing Address - Phone:240-704-1590
Mailing Address - Fax:
Practice Address - Street 1:506 CHILLUM RD APT 102
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20783
Practice Address - Country:US
Practice Address - Phone:240-704-1590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide