Basic Information
| Provider Information | |||||||||
| NPI: | 1962742973 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTERS | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLEIL | ||||||||
| OtherFirstName: | JESSICA | ||||||||
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| OtherCredential: | PHD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11279 PERRY HWY | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | WEXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150909381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249331100 | ||||||||
| FaxNumber: | 7249331105 | ||||||||
| Practice Location | |||||||||
| Address1: | 4117 PENN AVE | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152241305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249333910 | ||||||||
| FaxNumber: | 7249334508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2013 | ||||||||
| LastUpdateDate: | 02/28/2013 | ||||||||
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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 | 103G00000X | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.