Provider Demographics
NPI:1962548495
Name:WALSH, JACQUELINE T (OD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:T
Last Name:WALSH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:10522 SANTA GERTRUDES AVE
Mailing Address - Street 2:APT 26
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90603-2762
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10522 SANTA GERTRUDES AVE
Practice Address - Street 2:APT 26
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90603-2762
Practice Address - Country:US
Practice Address - Phone:562-236-7395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5166637-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist