Provider Demographics
NPI:1780861823
Name:WALTERS, JESSICA LAURA (MA)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:LAURA
Last Name:WALTERS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6330 W THUNDERBIRD RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4002
Mailing Address - Country:US
Mailing Address - Phone:623-487-5192
Mailing Address - Fax:623-487-5197
Practice Address - Street 1:12901 N 63RD AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1701
Practice Address - Country:US
Practice Address - Phone:623-412-4750
Practice Address - Fax:623-412-4755
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3860225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist