Provider Demographics
NPI:1750420857
Name:WALTON, JEREMY PAUL (DC)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:PAUL
Last Name:WALTON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7808 PACIFIC AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-7039
Mailing Address - Country:US
Mailing Address - Phone:253-474-3770
Mailing Address - Fax:253-472-5004
Practice Address - Street 1:7808 PACIFIC AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-7039
Practice Address - Country:US
Practice Address - Phone:253-474-3770
Practice Address - Fax:253-472-5004
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001283111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2034502Medicaid
WA001001285Medicare ID - Type Unspecified
WAT02815Medicare UPIN