Provider Demographics
NPI:1275645145
Name:WALDEN, JACCI GAYLE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACCI
Middle Name:GAYLE
Last Name:WALDEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3504 CORINTH PARKWAY
Mailing Address - Street 2:SUITE 150
Mailing Address - City:CORINTH
Mailing Address - State:TX
Mailing Address - Zip Code:76208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3504 CORINTH PARKWAY
Practice Address - Street 2:SUITE 150
Practice Address - City:CORINTH
Practice Address - State:TX
Practice Address - Zip Code:76208
Practice Address - Country:US
Practice Address - Phone:940-498-4445
Practice Address - Fax:940-270-5002
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4162207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
8B2469Medicare ID - Type Unspecified
H50998Medicare UPIN