Provider Demographics
NPI:1659193175
Name:WALSTON, JENNIFER ANN (CPHT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:WALSTON
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1644 N HARGRAVE ST
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-2246
Mailing Address - Country:US
Mailing Address - Phone:909-583-5229
Mailing Address - Fax:
Practice Address - Street 1:1644 N HARGRAVE ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-2246
Practice Address - Country:US
Practice Address - Phone:909-583-5229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60238183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician