Healthcare Provider Details

I. General information

NPI: 1699766089
Provider Name (Legal Business Name): JERRY W WALKER LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 09/10/2023
Certification Date: 09/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 N DUQUESNE RD
JOPLIN MO
64801-1509
US

IV. Provider business mailing address

1230 N DUQUESNE RD
JOPLIN MO
64801-1509
US

V. Phone/Fax

Practice location:
  • Phone: 417-782-1443
  • Fax: 417-782-3240
Mailing address:
  • Phone: 417-782-1443
  • Fax: 417-782-3240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2000167859
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: