Provider Demographics
NPI:1033656939
Name:WALLS, JACQUELINE THOMAS
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:THOMAS
Last Name:WALLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:DENISE
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:803 FLOYD AVE
Mailing Address - Street 2:
Mailing Address - City:DEMOPOLIS
Mailing Address - State:AL
Mailing Address - Zip Code:36732-3157
Mailing Address - Country:US
Mailing Address - Phone:334-349-6916
Mailing Address - Fax:
Practice Address - Street 1:803 FLOYD AVE
Practice Address - Street 2:
Practice Address - City:DEMOPOLIS
Practice Address - State:AL
Practice Address - Zip Code:36732-3157
Practice Address - Country:US
Practice Address - Phone:334-349-6916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-080172163W00000X
320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No163W00000XNursing Service ProvidersRegistered Nurse