Provider Demographics
NPI:1902531239
Name:WALTER, JACQUELYN (CNP)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:WALTER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41800 W 11 MILE RD STE 109
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-1818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:836 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28560-3445
Practice Address - Country:US
Practice Address - Phone:252-638-9304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGAA-NP002166363L00000X
FLAPRN11031772363L00000X
OHAPRN.CNP.0030568363LF0000X
IN71013523A363LF0000X
MI4704401200363LF0000X
KY3019140363LF0000X
IAA178270363LF0000X
KS53-82882-101363LF0000X
NC5016637363LF0000X
NH093444-23363L00000X
VA0024189150363L00000X
MO2024005128363L00000X
COC-APN.0102468-C-NP363L00000X
COC-RXN.0101627-C-NP363L00000X
TNAPN0000035840363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner