Provider Demographics
NPI:1659191633
Name:MOHAMED, JAMA
Entity type:Individual
Prefix:
First Name:JAMA
Middle Name:
Last Name:MOHAMED
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 1:430 MENDOTA RD W APT 216
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-4761
Mailing Address - Country:US
Mailing Address - Phone:817-323-6760
Mailing Address - Fax:
Practice Address - Street 1:4981 MARSH RD
Practice Address - Street 2:
Practice Address - City:MCFARLAND
Practice Address - State:WI
Practice Address - Zip Code:53558-8630
Practice Address - Country:US
Practice Address - Phone:817-323-6760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0020340310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility