Provider Demographics
NPI:1306996996
Name:WALKER, JAY EVAN (COTA-L)
Entity type:Individual
Prefix:MR
First Name:JAY
Middle Name:EVAN
Last Name:WALKER
Suffix:
Gender:M
Credentials:COTA-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16408 HIGHWAY 80
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:MS
Mailing Address - Zip Code:39332-3332
Mailing Address - Country:US
Mailing Address - Phone:601-646-6049
Mailing Address - Fax:
Practice Address - Street 1:711 AVIGNON DR
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-5120
Practice Address - Country:US
Practice Address - Phone:601-605-6777
Practice Address - Fax:601-605-8869
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA1619224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant