Provider Demographics
NPI:1811882533
Name:WALTON, JENNELLE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNELLE
Middle Name:
Last Name:WALTON
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 1:1663 CTY RTE 22
Mailing Address - Street 2:
Mailing Address - City:GOUVERNEUR
Mailing Address - State:NY
Mailing Address - Zip Code:13642-3356
Mailing Address - Country:US
Mailing Address - Phone:315-276-1866
Mailing Address - Fax:
Practice Address - Street 1:117 N MECHANIC ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619-1252
Practice Address - Country:US
Practice Address - Phone:315-493-4187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-11
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant