Provider Demographics
NPI:1073579454
Name:WALL, JALYN (CFNP)
Entity Type:Individual
Prefix:
First Name:JALYN
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5219 CITY BANK PKWY STE 35
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-3545
Mailing Address - Country:US
Mailing Address - Phone:806-761-0333
Mailing Address - Fax:806-785-7685
Practice Address - Street 1:4004 82ND ST STE G
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-2065
Practice Address - Country:US
Practice Address - Phone:806-792-1050
Practice Address - Fax:806-795-1965
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXAP108953363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149472601Medicaid
S62520Medicare UPIN
TX149472601Medicaid