Provider Demographics
NPI:1568656767
Name:WALLER, JAMIE STAR
Entity Type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:STAR
Last Name:WALLER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JAMIE
Other - Middle Name:STAR
Other - Last Name:BLAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2101 COURAGE DR
Mailing Address - Street 2:MS 10-300
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-6717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2101 COURAGE DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6717
Practice Address - Country:US
Practice Address - Phone:707-784-2180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-30
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator