Basic Information
| Provider Information | |||||||||
| NPI: | 1831735042 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALTER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | APRN-CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 ACKERMAN RD STE 2120 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432021559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142933230 | ||||||||
| FaxNumber: | 6142934030 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 ZOLLINGER RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432212849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142933230 | ||||||||
| FaxNumber: | 6142934030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2019 | ||||||||
| LastUpdateDate: | 04/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APRN.CNP.022948 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0396573 | 05 | OH | MEDICAID |