Provider Demographics
NPI:1093542946
Name:NIKUBWAYO, JEAN CLEMENT (ARNP)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:CLEMENT
Last Name:NIKUBWAYO
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2428 W REYNOLDS AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-4554
Mailing Address - Country:US
Mailing Address - Phone:360-330-9044
Mailing Address - Fax:360-736-0689
Practice Address - Street 1:3510 STEELHAMMER DR
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-1532
Practice Address - Country:US
Practice Address - Phone:360-623-8020
Practice Address - Fax:360-623-1072
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61576057363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health