Provider Demographics
NPI:1114407939
Name:WALKER, JESSICA CLARK
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:CLARK
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 1:119 HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:HOLLY RIDGE
Mailing Address - State:NC
Mailing Address - Zip Code:28445-7898
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:119 HOLLY ST
Practice Address - Street 2:
Practice Address - City:HOLLY RIDGE
Practice Address - State:NC
Practice Address - Zip Code:28445-7898
Practice Address - Country:US
Practice Address - Phone:910-329-1707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08063363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant