Provider Demographics
NPI:1497645667
Name:JACKSON, WALKER
Entity type:Individual
Prefix:
First Name:WALKER
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:WALKER
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MC
Mailing Address - Street 1:102 RIVERSIDE LN
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:LA
Mailing Address - Zip Code:71456-3430
Mailing Address - Country:US
Mailing Address - Phone:318-609-8274
Mailing Address - Fax:
Practice Address - Street 1:708 BROADWAY STE 170
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-3778
Practice Address - Country:US
Practice Address - Phone:253-640-4049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-08
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61670333101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health