Provider Demographics
NPI:1700596129
Name:WALTHER, JACQUELYN SUSAN
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:SUSAN
Last Name:WALTHER
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 1:1 FRESNO ST
Mailing Address - Street 2:
Mailing Address - City:BARNEGAT
Mailing Address - State:NJ
Mailing Address - Zip Code:08005-2509
Mailing Address - Country:US
Mailing Address - Phone:540-878-6895
Mailing Address - Fax:
Practice Address - Street 1:1 FRESNO ST
Practice Address - Street 2:
Practice Address - City:BARNEGAT
Practice Address - State:NJ
Practice Address - Zip Code:08005-2509
Practice Address - Country:US
Practice Address - Phone:540-878-6895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty