Provider Demographics
NPI:1235231275
Name:WALKER, JAY WALLACE (OD)
Entity Type:Individual
Prefix:MR
First Name:JAY
Middle Name:WALLACE
Last Name:WALKER
Suffix:
Gender:M
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:PO BOX 480
Mailing Address - Street 2:
Mailing Address - City:MOLALLA
Mailing Address - State:OR
Mailing Address - Zip Code:97038
Mailing Address - Country:US
Mailing Address - Phone:503-829-9186
Mailing Address - Fax:503-829-8402
Practice Address - Street 1:502 E MAIN STREET
Practice Address - Street 2:
Practice Address - City:MOLALLA
Practice Address - State:OR
Practice Address - Zip Code:97038
Practice Address - Country:US
Practice Address - Phone:503-829-9186
Practice Address - Fax:503-829-8402
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2487ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR260661Medicaid
ORR0000PHDBLMedicare PIN
OR260661Medicaid