Provider Demographics
NPI:1043564123
Name:WALTER, JENNIFER JILL (MSW, LISW)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:JILL
Last Name:WALTER
Suffix:
Gender:F
Credentials:MSW, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3835 CASSIDY DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-3404
Mailing Address - Country:US
Mailing Address - Phone:937-266-7445
Mailing Address - Fax:
Practice Address - Street 1:1349 E STROOP RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-4925
Practice Address - Country:US
Practice Address - Phone:937-293-1115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.11001851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical