MEDICARE: DR. JACCI GAYLE WALDEN MD

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	207Q00000X	Family Medicine Physician	L4162	TX

General Provider Information

NPI Number	:	1275645145
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACCI GAYLE WALDEN MD

Provider Business Mailing Address
First Line	:	3504 CORINTH PARKWAY
Second Line	:	SUITE 150
City	:	CORINTH
State	:	TX
Zip	:	76208
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3504 CORINTH PARKWAY
Second Line	:	SUITE 150
City	:	CORINTH
State	:	TX
Zip	:	76208
Country	:	US
Telephone Number	:	940-498-4445
Fax Number	:	940-270-5002

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	02/09/2010

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