Provider Demographics
NPI:1952058794
Name:JALAB, MOHAMAD (RSA)
Entity Type:Individual
Prefix:
First Name:MOHAMAD
Middle Name:
Last Name:JALAB
Suffix:
Gender:M
Credentials:RSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19015 S JODI RD STE H
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8534
Mailing Address - Country:US
Mailing Address - Phone:708-995-5418
Mailing Address - Fax:
Practice Address - Street 1:19015 S JODI RD STE H
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8534
Practice Address - Country:US
Practice Address - Phone:708-995-5418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL238000603OtherILLINOIS DEPARTMENT OF PROFESSIONAL REGULATION