Healthcare Provider Details

I. General information

NPI: 1497212625
Provider Name (Legal Business Name): JACQUELYN GRACE WALKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2019
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15813 PAUL VEGA MD DR STE 100
HAMMOND LA
70403-1431
US

IV. Provider business mailing address

46204 RUFUS BANKSTON RD
HAMMOND LA
70401-6104
US

V. Phone/Fax

Practice location:
  • Phone: 985-230-2663
  • Fax:
Mailing address:
  • Phone: 573-821-0611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: