Provider Demographics
NPI:1437669413
Name:WALKER, JUSTIN FORD
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:FORD
Last Name:WALKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1629 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98363-5207
Mailing Address - Country:US
Mailing Address - Phone:541-580-6190
Mailing Address - Fax:
Practice Address - Street 1:1116 E LAURIDSEN BLVD
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6640
Practice Address - Country:US
Practice Address - Phone:360-452-9206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WALL60891499235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program