Healthcare Provider Details

I. General information

NPI: 1629386305
Provider Name (Legal Business Name): JASON WALTERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2010
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BULLDOG LN
HAZARD KY
41701-6081
US

IV. Provider business mailing address

2250 THUNDERSTICK DR 1104
LEXINGTON KY
40505-9415
US

V. Phone/Fax

Practice location:
  • Phone: 859-254-1035
  • Fax: 859-254-2075
Mailing address:
  • Phone: 859-254-1035
  • Fax: 859-254-2075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: