Provider Demographics
NPI:1639826662
Name:OMAR, JAMAL ALI JR
Entity Type:Individual
Prefix:MR
First Name:JAMAL
Middle Name:ALI
Last Name:OMAR
Suffix:JR
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 1:743 LAFOND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-1606
Mailing Address - Country:US
Mailing Address - Phone:651-529-5381
Mailing Address - Fax:
Practice Address - Street 1:428 CENTRAL AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-2248
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-09
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNC153041120609342000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes342000000XTransportation ServicesTransportation Network Company
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC153041120609Medicaid