Healthcare Provider Details

I. General information

NPI: 1104249523
Provider Name (Legal Business Name): JEFF WALKER CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2014
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 NAVE RD SE
MASSILLON OH
44646-9604
US

IV. Provider business mailing address

1341 MARKET AVE N
CANTON OH
44714-2605
US

V. Phone/Fax

Practice location:
  • Phone: 330-837-1883
  • Fax: 330-837-4603
Mailing address:
  • Phone: 330-452-8252
  • Fax: 330-453-6716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: