Provider Demographics
NPI:1548383367
Name:JURASCHKA, WALLY W (PHD)
Entity Type:Individual
Prefix:
First Name:WALLY
Middle Name:W
Last Name:JURASCHKA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 FAIRWAY OAKS DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38134-5587
Mailing Address - Country:US
Mailing Address - Phone:901-647-7822
Mailing Address - Fax:901-763-4060
Practice Address - Street 1:5575 POPLAR AVE STE 320
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3862
Practice Address - Country:US
Practice Address - Phone:901-763-0909
Practice Address - Fax:901-763-4060
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLMT 104 PE 151106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist