Provider Demographics
NPI:1629873120
Name:DAVID, JALIEAL
Entity type:Individual
Prefix:
First Name:JALIEAL
Middle Name:
Last Name:DAVID
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 1:4623 N 93RD ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68134-3901
Mailing Address - Country:US
Mailing Address - Phone:561-234-8058
Mailing Address - Fax:
Practice Address - Street 1:4623 N 93RD ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68134-3901
Practice Address - Country:US
Practice Address - Phone:561-234-8058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-18
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor