Provider Demographics
NPI:1669658993
Name:WALTER, JENNY VIOLET (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:VIOLET
Last Name:WALTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2616 KWINA RD
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-9291
Mailing Address - Country:US
Mailing Address - Phone:360-380-6945
Mailing Address - Fax:360-384-2350
Practice Address - Street 1:2616 KWINA RD
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-9291
Practice Address - Country:US
Practice Address - Phone:360-380-6945
Practice Address - Fax:360-384-2350
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA10005362363AM0700X
WAPA10005362363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8505596Medicaid