MEDICARE: DR. JENNIFER NICOLE WALSTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	021724	KY

General Provider Information

NPI Number	:	1629729421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER NICOLE WALSTON

Provider Business Mailing Address
First Line	:	755 LEBANON CHURCH RD
Second Line	:
City	:	PADUCAH
State	:	KY
Zip	:	42003-9224
Country	:	US
Telephone Number	:	270-559-3216
Fax Number	:

Provider Business Practice Location Address
First Line	:	250 LONE OAK RD STE A
Second Line	:
City	:	PADUCAH
State	:	KY
Zip	:	42001-4494
Country	:	US
Telephone Number	:	270-443-1442
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2022
Last Update Date	:	01/12/2022

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