Provider Demographics
NPI:1053096776
Name:JALO, MARYAM
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:JALO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1678 GRANITE HILLS DR
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019-2607
Mailing Address - Country:US
Mailing Address - Phone:619-627-5627
Mailing Address - Fax:
Practice Address - Street 1:3665 KEARNY VILLA RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1953
Practice Address - Country:US
Practice Address - Phone:858-576-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1242531041C0700X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program