Provider Demographics
NPI:1093390494
Name:COVIN, JALISA
Entity Type:Individual
Prefix:
First Name:JALISA
Middle Name:
Last Name:COVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 POINTE NORTH BLVD APT 226
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-1616
Mailing Address - Country:US
Mailing Address - Phone:229-255-6449
Mailing Address - Fax:
Practice Address - Street 1:2711 POINTE NORTH BLVD APT 226
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31721-1616
Practice Address - Country:US
Practice Address - Phone:229-255-6449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor