Provider Demographics
NPI:1831691708
Name:JALLOW, MOMODOU
Entity type:Individual
Prefix:
First Name:MOMODOU
Middle Name:
Last Name:JALLOW
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 1:2591 LYVONA LN
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99502-5452
Mailing Address - Country:US
Mailing Address - Phone:907-205-0394
Mailing Address - Fax:
Practice Address - Street 1:2591 LYVONA LN
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99502-5452
Practice Address - Country:US
Practice Address - Phone:907-205-0394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100880311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility