Provider Demographics
NPI:1356544829
Name:WALKER, JESSIE LEO (MASSAGE THERAPIST)
Entity type:Individual
Prefix:MR
First Name:JESSIE
Middle Name:LEO
Last Name:WALKER
Suffix:
Gender:M
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6272 E WINDSOR LN
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-1363
Mailing Address - Country:US
Mailing Address - Phone:770-934-5264
Mailing Address - Fax:
Practice Address - Street 1:6272 E WINDSOR LN
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-1363
Practice Address - Country:US
Practice Address - Phone:770-934-5264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT001245171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor