Basic Information
| Provider Information | |||||||||
| NPI: | 1558371229 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALKER | ||||||||
| FirstName: | JENNIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2485 | ||||||||
| Address2: | |||||||||
| City: | MAMMOTH LAKES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935462485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609343311 | ||||||||
| FaxNumber: | 7609244003 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 SIERRA PARK RD | ||||||||
| Address2: | |||||||||
| City: | MAMMOTH LAKES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935462073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609343311 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 01/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | A73644 | CA | N | Hospitals | General Acute Care Hospital | Critical Access | 207P00000X | A73644 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1558371229 | 05 | CA | MEDICAID |