Provider Demographics
NPI:1467510594
Name:WALRATH, JEAN W (LPO LMFT MED)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:W
Last Name:WALRATH
Suffix:
Gender:F
Credentials:LPO LMFT MED
Other - Prefix:MRS
Other - First Name:JEAN
Other - Middle Name:WALRATH
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:600 HOGAN STREET
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-3376
Mailing Address - Country:US
Mailing Address - Phone:662-323-8148
Mailing Address - Fax:662-323-1516
Practice Address - Street 1:600 HOGAN STREET
Practice Address - Street 2:SUITE 2C
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-3376
Practice Address - Country:US
Practice Address - Phone:662-323-8148
Practice Address - Fax:662-323-1516
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0801101YM0800X
MST0307106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist