Provider Demographics
NPI:1538999784
Name:ST JUDE THERAPY CENTER STAFFING
Entity type:Organization
Organization Name:ST JUDE THERAPY CENTER STAFFING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP-BC
Authorized Official - Prefix:
Authorized Official - First Name:JUDE
Authorized Official - Middle Name:OSAGIE
Authorized Official - Last Name:UKPEBOR
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:313-681-2209
Mailing Address - Street 1:27200 LAHSER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-2137
Mailing Address - Country:US
Mailing Address - Phone:313-681-2209
Mailing Address - Fax:
Practice Address - Street 1:27200 LAHSER RD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-2137
Practice Address - Country:US
Practice Address - Phone:313-681-2209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty