MEDICARE: JABRILL OMAR JIMAALE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343900000X	Non-emergency Medical Transport (VAN)	T950225934414	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	842077605	OTHER	TX	NON EMERGENCY MEDICAL TRANSPORTATION
2	842077605	OTHER	TX	NON EMERGENCY MEDICAL TRANPORTATION

General Provider Information

NPI Number	:	1912539024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JABRILL OMAR JIMAALE

Provider Business Mailing Address
First Line	:	5725 E LANCASTER AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-6528
Country	:	US
Telephone Number	:	817-851-1663
Fax Number	:	817-851-1664

Provider Business Practice Location Address
First Line	:	5725 E LANCASTER AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-6528
Country	:	US
Telephone Number	:	817-851-1663
Fax Number	:	817-851-1664

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2020
Last Update Date	:	02/06/2020

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Directions to “ JABRILL OMAR JIMAALE ” Practice Location

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