Provider Demographics
NPI:1861461485
Name:WALKER, JERRY DON (DC)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:DON
Last Name:WALKER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 BOLAND ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-1221
Mailing Address - Country:US
Mailing Address - Phone:817-332-1234
Mailing Address - Fax:817-332-1473
Practice Address - Street 1:105 BOLAND ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-1221
Practice Address - Country:US
Practice Address - Phone:817-332-1234
Practice Address - Fax:817-332-1473
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2534111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0200XChiropractic ProvidersChiropractorRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001062101Medicaid
TXT16453Medicare UPIN
TX001062101Medicaid