Provider Demographics
NPI:1063815835
Name:WALKER, JEANINE
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:
Last Name:WALKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8623 N WAYNE RD
Mailing Address - Street 2:SUITE 323
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-1137
Mailing Address - Country:US
Mailing Address - Phone:734-742-0605
Mailing Address - Fax:734-742-0608
Practice Address - Street 1:8623 N WAYNE RD
Practice Address - Street 2:SUITE 323
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-1137
Practice Address - Country:US
Practice Address - Phone:734-742-0605
Practice Address - Fax:734-742-0608
Is Sole Proprietor?:No
Enumeration Date:2014-10-07
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704232054163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI123123123Medicaid