Provider Demographics
NPI:1629380316
Name:WALCOTT, KENNIE NICOLE JACKSON
Entity Type:Individual
Prefix:MRS
First Name:KENNIE
Middle Name:NICOLE JACKSON
Last Name:WALCOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KENNIE
Other - Middle Name:NICOLE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3955 CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46226-4836
Mailing Address - Country:US
Mailing Address - Phone:317-362-3792
Mailing Address - Fax:
Practice Address - Street 1:3955 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-4836
Practice Address - Country:US
Practice Address - Phone:317-362-3792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No374700000XNursing Service Related ProvidersTechnician