Provider Demographics
NPI:1083870901
Name:WALLS, JAN
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:WALLS
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 1:852 ASBURY DR
Mailing Address - Street 2:
Mailing Address - City:NEW JOHNSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37134-9673
Mailing Address - Country:US
Mailing Address - Phone:931-380-8993
Mailing Address - Fax:
Practice Address - Street 1:852 ASBURY DR
Practice Address - Street 2:
Practice Address - City:NEW JOHNSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37134-9673
Practice Address - Country:US
Practice Address - Phone:931-380-8993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1745235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist