Provider Demographics
NPI:1104686971
Name:MOMODU, JEMINAT BOSE
Entity type:Individual
Prefix:
First Name:JEMINAT
Middle Name:BOSE
Last Name:MOMODU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 EASTERN AVE NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-3127
Mailing Address - Country:US
Mailing Address - Phone:240-795-8932
Mailing Address - Fax:
Practice Address - Street 1:4740 EASTERN AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-3127
Practice Address - Country:US
Practice Address - Phone:240-795-8932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-20
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA200003601251E00000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No251E00000XAgenciesHome Health