Healthcare Provider Details

I. General information

NPI: 1578719340
Provider Name (Legal Business Name): JESSE D WALDEN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2008
Last Update Date: 08/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11652 W. 75 ST.
SHAWNEE KS
66214
US

IV. Provider business mailing address

11652 W 75TH ST
SHAWNEE KS
66214-1372
US

V. Phone/Fax

Practice location:
  • Phone: 913-825-1235
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number01-05054
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: