Provider Demographics
NPI:1962406835
Name:NGANGA, JACKSON MAINA (MD)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:MAINA
Last Name:NGANGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 S OLD DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1210 S OLD DIXIE HWY
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7205
Practice Address - Country:US
Practice Address - Phone:561-263-2234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME132336208000000X
MDD0053131208000000X
WV21137208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3003924000Medicaid
WVNG2024201Medicare ID - Type Unspecified
WV3003924000Medicaid