Provider Demographics
NPI:1306360979
Name:WALKER, JACOB (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WALKER
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:944 FIELDS DR STE 102
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-5341
Mailing Address - Country:US
Mailing Address - Phone:270-495-1312
Mailing Address - Fax:
Practice Address - Street 1:980 MORGANTOWN RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-3644
Practice Address - Country:US
Practice Address - Phone:270-495-1312
Practice Address - Fax:270-495-1351
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-26
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY173818235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY242920OtherKENTUCKY SPEECH-LANGUAGE PATHOLOGY LICENSURE