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General NPI Number Information
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NPI Number | 1104351964
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Entity Type | Individual
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Provider Name | JONATHAN M WALLER MA CCC-SLP
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Gender | Male
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Dates
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Enumeration Date | 04/28/2017
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Last Update Date | 08/03/2020
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Provider Practice Location Address
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Address Line | 1100 N STATE ST CT A2E
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City | LOS ANGELES
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State | CA
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Zip | 90033-5000
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Country | US
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Telephone | 323-409-5082
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Fax |
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Provider Business Mailing Address
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Address Line | 1100 N STATE ST CT A2E
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City | LOS ANGELES
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State | CA
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Zip | 90033-5000
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Country | US
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Telephone | 323-409-5082
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 17522
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SLP010930
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License Number State | GA
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