Provider Demographics
NPI:1730492760
Name:WALKER, JARED B (CST/CSFA)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:B
Last Name:WALKER
Suffix:
Gender:M
Credentials:CST/CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 WILSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-7023
Mailing Address - Country:US
Mailing Address - Phone:229-630-6027
Mailing Address - Fax:
Practice Address - Street 1:4205 WILSHIRE DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-7023
Practice Address - Country:US
Practice Address - Phone:229-630-6027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA121136246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant