Provider Demographics
NPI:1255838470
Name:WALKER, JASMINE NICHOLE
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:NICHOLE
Last Name:WALKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 WARTBURG AVE
Mailing Address - Street 2:
Mailing Address - City:COPIAGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11726
Mailing Address - Country:US
Mailing Address - Phone:631-991-1694
Mailing Address - Fax:
Practice Address - Street 1:70 WARTBURG AVE
Practice Address - Street 2:
Practice Address - City:COPIAGUE
Practice Address - State:NY
Practice Address - Zip Code:11726
Practice Address - Country:US
Practice Address - Phone:631-991-1694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY103K00000XOtherABA THERAPY