Provider Demographics
NPI:1194091280
Name:WALTER, JESSICA REYNOLDS (PA-C)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:REYNOLDS
Last Name:WALTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9214 BARNSFORD LN
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77375-2218
Mailing Address - Country:US
Mailing Address - Phone:240-643-5008
Mailing Address - Fax:
Practice Address - Street 1:26500 KUYKENDAHL RD
Practice Address - Street 2:
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375
Practice Address - Country:US
Practice Address - Phone:281-516-7234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07756363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant