Provider Demographics
NPI:1992455117
Name:WANJIRU-NWUZOR, JACKIE (CRNP-PMH)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:WANJIRU-NWUZOR
Suffix:
Gender:F
Credentials:CRNP-PMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 W 58TH ST APT 12H
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1834
Mailing Address - Country:US
Mailing Address - Phone:443-768-5820
Mailing Address - Fax:
Practice Address - Street 1:330 W 58TH ST APT 12H
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1834
Practice Address - Country:US
Practice Address - Phone:443-768-5820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-29
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY404056363LP0808X, 364SP0808X
MDR195623363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health