Provider Demographics
NPI:1609368422
Name:JAMA, EDIL
Entity type:Individual
Prefix:
First Name:EDIL
Middle Name:
Last Name:JAMA
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 1:4547 BIRCH RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-5605
Mailing Address - Country:US
Mailing Address - Phone:404-910-6174
Mailing Address - Fax:
Practice Address - Street 1:4547 BIRCH RIDGE TRL
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-5605
Practice Address - Country:US
Practice Address - Phone:404-910-6174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0032041897Medicaid