Provider Demographics
NPI:1679196125
Name:WALTERS, JARROD ALAN
Entity Type:Individual
Prefix:
First Name:JARROD
Middle Name:ALAN
Last Name:WALTERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 FECHNER CIR
Mailing Address - Street 2:
Mailing Address - City:NORTH AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60542-1807
Mailing Address - Country:US
Mailing Address - Phone:812-361-5859
Mailing Address - Fax:
Practice Address - Street 1:4455 WEAVER PKWY
Practice Address - Street 2:
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-3269
Practice Address - Country:US
Practice Address - Phone:630-821-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL4713172471R0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471R0002XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiation Therapy