Provider Demographics
NPI:1881889509
Name:WALKER, JACQUELYN MARIE (PT)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MARIE
Last Name:WALKER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:MARIE
Other - Last Name:MASEPHOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:N9520 ZEITZ RD
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN DELLS
Mailing Address - State:WI
Mailing Address - Zip Code:53965-9422
Mailing Address - Country:US
Mailing Address - Phone:608-217-1460
Mailing Address - Fax:
Practice Address - Street 1:613 BROADWAY UNIT 3
Practice Address - Street 2:
Practice Address - City:WISCONSIN DELLS
Practice Address - State:WI
Practice Address - Zip Code:53965-1553
Practice Address - Country:US
Practice Address - Phone:608-432-5866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10461-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist