Healthcare Provider Details

I. General information

NPI: 1689855934
Provider Name (Legal Business Name): JENNIFER L WALKER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2007
Last Update Date: 09/24/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9901 EMMAUS
ST JOHN VI
00830-9587
US

IV. Provider business mailing address

9901 EMMAUS
ST JOHN VI
00830-9587
US

V. Phone/Fax

Practice location:
  • Phone: 340-642-2652
  • Fax:
Mailing address:
  • Phone: 340-642-2652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01076424A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35663
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2725
License Number StateVI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: