Provider Demographics
NPI:1285296384
Name:IWEBO, JANE NGOZI (PMHNP)
Entity type:Individual
Prefix:MS
First Name:JANE
Middle Name:NGOZI
Last Name:IWEBO
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:MS
Other - First Name:JANE
Other - Middle Name:NGOZI
Other - Last Name:NWABUFO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1978
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21802-1978
Mailing Address - Country:US
Mailing Address - Phone:410-749-1015
Mailing Address - Fax:410-749-0654
Practice Address - Street 1:560 RIVERSIDE DR STE A204
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-4704
Practice Address - Country:US
Practice Address - Phone:443-358-6193
Practice Address - Fax:443-358-6197
Is Sole Proprietor?:No
Enumeration Date:2019-06-28
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR128087363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health