Provider Demographics
NPI:1124848130
Name:WALBURN, JESSEE DYLAN
Entity type:Individual
Prefix:
First Name:JESSEE
Middle Name:DYLAN
Last Name:WALBURN
Suffix:
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 1:415 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:STARK CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64866-9627
Mailing Address - Country:US
Mailing Address - Phone:417-602-9219
Mailing Address - Fax:
Practice Address - Street 1:415 SOUTH ST
Practice Address - Street 2:
Practice Address - City:STARK CITY
Practice Address - State:MO
Practice Address - Zip Code:64866-9627
Practice Address - Country:US
Practice Address - Phone:417-602-9219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty