Basic Information
| Provider Information | |||||||||
| NPI: | 1992141261 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTER | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | PHD, LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2356 UNIVERSITY AVE W | ||||||||
| Address2: | SUITE 430 | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551141853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6124364818 | ||||||||
| FaxNumber: | 6124364800 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 CHURCH ST SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554550222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126241444 | ||||||||
| FaxNumber: | 6126257155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2013 | ||||||||
| LastUpdateDate: | 02/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP5615 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.