Provider Demographics
NPI:1609618362
Name:EGBON, JOLLY
Entity type:Individual
Prefix:
First Name:JOLLY
Middle Name:
Last Name:EGBON
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 1:2853 BRENTWOOD RD NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20018-2609
Mailing Address - Country:US
Mailing Address - Phone:240-370-4891
Mailing Address - Fax:
Practice Address - Street 1:3001 BLADENSBURG RD NE APT N0301
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-2235
Practice Address - Country:US
Practice Address - Phone:240-370-4891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant