Provider Demographics
NPI:1962763474
Name:EBEN MBOE, JACOB MBENG
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:MBENG
Last Name:EBEN MBOE
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 1:14111 BOWSPRIT LN APT 210
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-6328
Mailing Address - Country:US
Mailing Address - Phone:240-554-7027
Mailing Address - Fax:
Practice Address - Street 1:14111 BOWSPRIT LN APT 210
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-6328
Practice Address - Country:US
Practice Address - Phone:240-554-7027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide