Healthcare Provider Details

I. General information

NPI: 1467143164
Provider Name (Legal Business Name): JARVIS WALKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 SPENCER RD
SAINT PETERS MO
63376-2438
US

IV. Provider business mailing address

1523 SOUTH ST
VICKSBURG MS
39180-3343
US

V. Phone/Fax

Practice location:
  • Phone: 636-477-9911
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7266
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: