Provider Demographics
NPI:1770758427
Name:PUCKETT, JENNIFER WALKER (MT-BC, NMT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:WALKER
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:MT-BC, NMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5121
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-0033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2180 RIDGE RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-4187
Practice Address - Country:US
Practice Address - Phone:678-231-6692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA07335225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist