Provider Demographics
NPI:1538984414
Name:WALTERS, JACLYN MARIE
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARIE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 THERESA DR
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-9637
Mailing Address - Country:US
Mailing Address - Phone:304-479-9378
Mailing Address - Fax:
Practice Address - Street 1:224 THERESA DR
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-9637
Practice Address - Country:US
Practice Address - Phone:304-479-9378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-18
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency