Basic Information
| Provider Information | |||||||||
| NPI: | 1922400811 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALKER | ||||||||
| FirstName: | JACQUELINE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 E DUPONT RD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739700 | ||||||||
| FaxNumber: | 2603739740 | ||||||||
| Practice Location | |||||||||
| Address1: | 20045 N. 19TH AVENUE | ||||||||
| Address2: | BLDG 10, SUITE 3 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806262552 | ||||||||
| FaxNumber: | 4806262551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2014 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | IN | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363LF0000X | AP8982 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 209109 | 05 | AZ | MEDICAID |