Provider Demographics
NPI:1982168332
Name:WALTON, JENNIFER HAINES (LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:HAINES
Last Name:WALTON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 CIRCLE H LN
Mailing Address - Street 2:
Mailing Address - City:CLIFTON FORGE
Mailing Address - State:VA
Mailing Address - Zip Code:24422-3529
Mailing Address - Country:US
Mailing Address - Phone:540-968-0872
Mailing Address - Fax:
Practice Address - Street 1:501 E RIDGEWAY ST STE B
Practice Address - Street 2:
Practice Address - City:CLIFTON FORGE
Practice Address - State:VA
Practice Address - Zip Code:24422-1328
Practice Address - Country:US
Practice Address - Phone:540-968-0872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000807171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist