Provider Demographics
NPI:1306615885
Name:JALLAH, ELIZABETH KORTU
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:KORTU
Last Name:JALLAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:KORTU
Other - Last Name:SEGRAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:783 EDENBERRY LN
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-2942
Mailing Address - Country:US
Mailing Address - Phone:678-778-4434
Mailing Address - Fax:
Practice Address - Street 1:783 EDENBERRY LN
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-2942
Practice Address - Country:US
Practice Address - Phone:678-778-4434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN203894363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health