Provider Demographics
NPI:1679084438
Name:WALTER, JESSICA LYNN (PHARMD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:WALTER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15509 BORMAN ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68138-7435
Mailing Address - Country:US
Mailing Address - Phone:402-659-0502
Mailing Address - Fax:
Practice Address - Street 1:13155 W CENTER RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-3740
Practice Address - Country:US
Practice Address - Phone:402-334-9134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22989183500000X
NE15399183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist