Provider Demographics
NPI:1992141261
Name:WALTER, JEFFREY P (PHD, LP)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:P
Last Name:WALTER
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2356 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 430
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1853
Mailing Address - Country:US
Mailing Address - Phone:612-436-4818
Mailing Address - Fax:612-436-4800
Practice Address - Street 1:410 CHURCH ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0222
Practice Address - Country:US
Practice Address - Phone:612-624-1444
Practice Address - Fax:612-625-7155
Is Sole Proprietor?:No
Enumeration Date:2013-05-14
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5615103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist