Basic Information
| Provider Information | |||||||||
| NPI: | 1295021541 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALKER | ||||||||
| FirstName: | JEFFERY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | F.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 702 4TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | CONOVER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286131619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286955900 | ||||||||
| FaxNumber: | 8286954256 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 ROCK BARN RD NE | ||||||||
| Address2: | |||||||||
| City: | CONOVER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286139727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8289944898 | ||||||||
| FaxNumber: | 8289944898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2011 | ||||||||
| LastUpdateDate: | 12/12/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 5005188 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LF0000X | 5005188 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1124559331 | 05 | NC | MEDICAID | 1295021541 | 05 | NC | MEDICAID | 7004992 | 05 | NC | MEDICAID |