Provider Demographics
NPI:1245533884
Name:WALKER, JESSICA BLACK (MSN, CPNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:BLACK
Last Name:WALKER
Suffix:
Gender:F
Credentials:MSN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 NEWTOWN PIKE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40508-1113
Mailing Address - Country:US
Mailing Address - Phone:615-364-5510
Mailing Address - Fax:
Practice Address - Street 1:650 NEWTOWN PIKE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-1113
Practice Address - Country:US
Practice Address - Phone:615-364-5510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-20
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000015422363LP0200X
KY3007468363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics