Provider Demographics
NPI:1881155729
Name:WALTER, JORDYN (MD)
Entity type:Individual
Prefix:
First Name:JORDYN
Middle Name:
Last Name:WALTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JORDYN
Other - Middle Name:
Other - Last Name:FARRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:424 W STATE HIGHWAY 5
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1723
Mailing Address - Country:US
Mailing Address - Phone:952-442-4461
Mailing Address - Fax:
Practice Address - Street 1:424 W STATE HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1723
Practice Address - Country:US
Practice Address - Phone:952-442-4461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-25
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN68084207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1881155729Medicaid