Healthcare Provider Details

I. General information

NPI: 1235225095
Provider Name (Legal Business Name): JACQUELINE L WALKER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 E PARK AVE STE 112
STATE COLLEGE PA
16803-6706
US

IV. Provider business mailing address

P.O. BOX 858 MC A410
HERSHEY PA
17033-0858
US

V. Phone/Fax

Practice location:
  • Phone: 800-243-1455
  • Fax:
Mailing address:
  • Phone: 800-243-1455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA054312
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA054312
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number01018
License Number StateWV

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1031923630002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: