Provider Demographics
NPI:1114404456
Name:WALTER, JESSICA S (OD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:S
Last Name:WALTER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 HAMBLEY BLVD OFC 401A
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-9114
Mailing Address - Country:US
Mailing Address - Phone:606-218-4473
Mailing Address - Fax:
Practice Address - Street 1:810 HAMBLEY BLVD
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-9114
Practice Address - Country:US
Practice Address - Phone:606-218-5540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005145152W00000X
KY2206DT152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management