Healthcare Provider Details

I. General information

NPI: 1285524967
Provider Name (Legal Business Name): JELICKA M MALLORY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2025
Last Update Date: 07/07/2025
Certification Date: 07/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 GUNBOAT DR # 17
COLUMBUS GA
31907-1498
US

IV. Provider business mailing address

5401 GUNBOAT DR # 17
COLUMBUS GA
31907-1498
US

V. Phone/Fax

Practice location:
  • Phone: 706-221-2626
  • Fax:
Mailing address:
  • Phone: 706-221-2626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: