Healthcare Provider Details

I. General information

NPI: 1912826835
Provider Name (Legal Business Name): JENNIFER LYNN WALLS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 12TH STREET EXT
PRINCETON WV
24740-2398
US

IV. Provider business mailing address

200 12TH STREET EXT
PRINCETON WV
24740-2398
US

V. Phone/Fax

Practice location:
  • Phone: 304-732-6043
  • Fax: 951-944-0592
Mailing address:
  • Phone: 304-732-6043
  • Fax: 951-944-0592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: