Provider Demographics
NPI:1558123760
Name:JALLOH, KHADIJAH (FNP)
Entity Type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:
Last Name:JALLOH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8850 GARRETT ST
Mailing Address - Street 2:
Mailing Address - City:LEWIS CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43035-8474
Mailing Address - Country:US
Mailing Address - Phone:240-643-0843
Mailing Address - Fax:
Practice Address - Street 1:8850 GARRETT ST
Practice Address - Street 2:
Practice Address - City:LEWIS CENTER
Practice Address - State:OH
Practice Address - Zip Code:43035-8474
Practice Address - Country:US
Practice Address - Phone:240-643-0843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2022007293363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily