Provider Demographics
NPI:1659381572
Name:WALCZYK, JACQUELINE R (ANP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:R
Last Name:WALCZYK
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13505 NW COUNTRYVIEW WAY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-4470
Mailing Address - Country:US
Mailing Address - Phone:503-220-8262
Mailing Address - Fax:503-402-2817
Practice Address - Street 1:3710 SW US VETERANS HOSPITAL RD
Practice Address - Street 2:MAIL CODE P3 R & D 42
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2964
Practice Address - Country:US
Practice Address - Phone:503-220-8262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR081002389N3363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner