Provider Demographics
NPI:1679270037
Name:MOHAMED, ISMAHAN JAAMA
Entity Type:Individual
Prefix:
First Name:ISMAHAN
Middle Name:JAAMA
Last Name:MOHAMED
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 1:3533 DUPONT AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-4009
Mailing Address - Country:US
Mailing Address - Phone:612-208-0729
Mailing Address - Fax:612-354-3801
Practice Address - Street 1:7205 UNIVERSITY AVE NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-3134
Practice Address - Country:US
Practice Address - Phone:612-208-0729
Practice Address - Fax:612-354-3801
Is Sole Proprietor?:No
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician