Provider Demographics
NPI:1376528216
Name:WALTERS, JENNIFER (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 SPRINGHURST BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-6156
Mailing Address - Country:US
Mailing Address - Phone:025-156-0905
Mailing Address - Fax:502-883-0016
Practice Address - Street 1:4201 SPRINGHURST BLVD STE 102
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-6156
Practice Address - Country:US
Practice Address - Phone:025-156-0905
Practice Address - Fax:502-883-0016
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA866363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95004818Medicaid
KY95004818Medicaid
KY00187007Medicare Oscar/Certification