MEDICARE: JESSICA CLARK WALKER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0010-08063	NC

General Provider Information

NPI Number	:	1114407939
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA CLARK WALKER

Provider Business Mailing Address
First Line	:	119 HOLLY ST
Second Line	:
City	:	HOLLY RIDGE
State	:	NC
Zip	:	28445-7898
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	119 HOLLY ST
Second Line	:
City	:	HOLLY RIDGE
State	:	NC
Zip	:	28445-7898
Country	:	US
Telephone Number	:	910-329-1707
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2018
Last Update Date	:	10/20/2022

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