Provider Demographics
NPI:1497353148
Name:WALLS, JENNIFER ELIZABETH (LMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELIZABETH
Last Name:WALLS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 JOE YENNI BLVD APT 18
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065
Mailing Address - Country:US
Mailing Address - Phone:504-250-3962
Mailing Address - Fax:
Practice Address - Street 1:4416 TRENTON ST
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-6527
Practice Address - Country:US
Practice Address - Phone:504-250-3962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA2119225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist