Basic Information
| Provider Information | |||||||||
| NPI: | 1255528725 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JALLAD | ||||||||
| FirstName: | MOHAMMED | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5210 OLDE RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435601883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192913627 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4235 SECOR RD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436234231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194795560 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SE0003X | NP09579 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Emergency | 363L00000X | RN-303351 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0051000 | 05 | OH | MEDICAID | 1255528725 | 05 | MI | MEDICAID |