Provider Demographics
NPI:1629471297
Name:WALSTON, JENNIFER L (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:WALSTON
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:RAINES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:751 N RUTLEDGE ST
Mailing Address - Street 2:PO BOX 19636
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-4968
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-7063
Practice Address - Street 1:751 N RUTLEDGE ST
Practice Address - Street 2:SUITE 1700
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4968
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-7063
Is Sole Proprietor?:No
Enumeration Date:2014-09-26
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011920363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
ILF400182887Medicare PIN