Healthcare Provider Details

I. General information

NPI: 1407741655
Provider Name (Legal Business Name): HALLA MAHMOUD JIBREEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2025
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1459 LANEY WALKER BLVD AE-3040
AUGUSTA GA
30912
US

IV. Provider business mailing address

1209 COLONY BEND CT
LAWRENCEVILLE GA
30043-8601
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-7005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number17939
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: