Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | 26NJ01229900 | NJ |
NPI | 1013673912 |
---|---|
Provider Name | Dr. Ricky James Jewell |
First Address | Bloomingdale, NJ 07403-1515 |
Second Address | Paramus, NJ 07652-4142 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/11/2021 |
Last Update Date | 15/11/2021 |