Provider Demographics
NPI:1497520480
Name:JALLOW, ALIEU ESSA
Entity Type:Individual
Prefix:
First Name:ALIEU
Middle Name:ESSA
Last Name:JALLOW
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 1:1408 MILL POND DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-3088
Mailing Address - Country:US
Mailing Address - Phone:248-767-3405
Mailing Address - Fax:
Practice Address - Street 1:1408 MILL POND DR
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-3088
Practice Address - Country:US
Practice Address - Phone:248-767-3405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-20
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704285372363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health