Provider Demographics
NPI:1275125890
Name:WALTERS, JODI
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:
Other - Last Name:INGLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:3707 BALBOA TER UNIT A
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-5463
Mailing Address - Country:US
Mailing Address - Phone:858-999-5622
Mailing Address - Fax:
Practice Address - Street 1:3003 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2700
Practice Address - Country:US
Practice Address - Phone:858-939-4779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA646460163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant