Provider Demographics
NPI:1043519523
Name:WALKER, JENNIFER COTMAN (AUD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:COTMAN
Last Name:WALKER
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3017 13TH ST
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-1833
Mailing Address - Country:US
Mailing Address - Phone:228-863-6617
Mailing Address - Fax:228-863-1747
Practice Address - Street 1:3017 13TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-1833
Practice Address - Country:US
Practice Address - Phone:228-863-6617
Practice Address - Fax:228-863-1747
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO607231H00000X
MSA3785231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1043519523Medicaid
KS200750450AMedicaid
CO75180081Medicaid
NE10025887900Medicaid
WYWOJO1984Medicaid