Provider Demographics
NPI:1760209415
Name:WALKER, JASPER SR
Entity type:Individual
Prefix:
First Name:JASPER
Middle Name:
Last Name:WALKER
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304-3711
Mailing Address - Country:US
Mailing Address - Phone:201-699-7382
Mailing Address - Fax:
Practice Address - Street 1:374 COMMUNIPAW AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07304-3724
Practice Address - Country:US
Practice Address - Phone:201-433-1888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYLA1122593302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization