Provider Demographics
NPI:1912539024
Name:JIMAALE, JABRILL OMAR
Entity Type:Individual
Prefix:
First Name:JABRILL
Middle Name:OMAR
Last Name:JIMAALE
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 1:5725 E LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-6528
Mailing Address - Country:US
Mailing Address - Phone:817-851-1663
Mailing Address - Fax:817-851-1664
Practice Address - Street 1:5725 E LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-6528
Practice Address - Country:US
Practice Address - Phone:817-851-1663
Practice Address - Fax:817-851-1664
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNT950225934414343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX842077605OtherNON EMERGENCY MEDICAL TRANSPORTATION
TX842077605OtherNON EMERGENCY MEDICAL TRANPORTATION