Provider Demographics
NPI:1598153280
Name:WALTERS, JEROME SR (CDP)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:WALTERS
Suffix:SR
Gender:M
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 48322
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98148-0322
Mailing Address - Country:US
Mailing Address - Phone:206-747-6446
Mailing Address - Fax:
Practice Address - Street 1:3715 S 141ST ST APT 6
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98168-4049
Practice Address - Country:US
Practice Address - Phone:206-747-6446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-03
Last Update Date:2015-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00006135101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)