Basic Information
Provider Information | |||||||||
NPI: | 1396185567 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EMELUMBA | ||||||||
FirstName: | JUDE | ||||||||
MiddleName: | CHINETO | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | APN, PMHNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 272 FORREST ST | ||||||||
Address2: |   | ||||||||
City: | JERSEY CITY | ||||||||
State: | NJ | ||||||||
PostalCode: | 073042239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5512478105 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 314 E STATE ST | ||||||||
Address2: |   | ||||||||
City: | TRENTON | ||||||||
State: | NJ | ||||||||
PostalCode: | 08608 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6093965944 | ||||||||
FaxNumber: | 6093940405 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/02/2013 | ||||||||
LastUpdateDate: | 10/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/05/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 26NJ00443500 | NJ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 0382914 | 05 | NJ |   | MEDICAID |