Basic Information
| Provider Information | |||||||||
| NPI: | 1285997163 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OKIDEGBE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | MSN, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5281 N 99TH AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853052209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235168252 | ||||||||
| FaxNumber: | 6236918502 | ||||||||
| Practice Location | |||||||||
| Address1: | 9250 W THOMAS RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850373382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235168252 | ||||||||
| FaxNumber: | 6235168253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2012 | ||||||||
| LastUpdateDate: | 03/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP4483 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 713001 | 05 | AZ | MEDICAID |