Provider Demographics
NPI:1730578311
Name:WALKER, JACKIE (LM, CPM)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:WALKER
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 NE TALBOTT DR
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-3544
Mailing Address - Country:US
Mailing Address - Phone:805-610-3943
Mailing Address - Fax:
Practice Address - Street 1:1417 NE TALBOTT DR
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-3544
Practice Address - Country:US
Practice Address - Phone:805-610-3943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-20
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA421176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA421OtherCALIFORNIA MEDICAL BOARD
OR10183250OtherOREGON HEALTH AUTHORITY LICENSE