Provider Demographics
NPI:1922240662
Name:WALNOHA, JENNIFER (MSOT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WALNOHA
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 LAKE BOONE TRL
Mailing Address - Street 2:SUITE 4
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7512
Mailing Address - Country:US
Mailing Address - Phone:919-781-4434
Mailing Address - Fax:
Practice Address - Street 1:4201 LAKE BOONE TRL
Practice Address - Street 2:SUITE 4
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7512
Practice Address - Country:US
Practice Address - Phone:919-781-4434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-26
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056008610225X00000X
NC8432225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4117OtherHAMP PROVIDER ID
IL203OtherBLUE CROSS PROV ID
IL7216OtherPERSONALCARE PROV ID
113326OtherHEALTHLINK PROV ID
IL4117OtherHAMP PROVIDER ID