Provider Demographics
NPI:1326635830
Name:WALLS, JAMIE (MS, LPC)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:WALLS
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 S 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-5242
Mailing Address - Country:US
Mailing Address - Phone:715-848-1457
Mailing Address - Fax:715-848-2959
Practice Address - Street 1:705 S 24TH AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-5242
Practice Address - Country:US
Practice Address - Phone:715-848-1457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA101184101YM0800X
WI10079-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health