Provider Demographics
NPI:1629729421
Name:WALSTON, JENNIFER NICOLE
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:NICOLE
Last Name:WALSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 LEBANON CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-9224
Mailing Address - Country:US
Mailing Address - Phone:270-559-3216
Mailing Address - Fax:
Practice Address - Street 1:250 LONE OAK RD STE A
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-4494
Practice Address - Country:US
Practice Address - Phone:270-443-1442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY021724183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist