Basic Information
| Provider Information | |||||||||
| NPI: | 1710058839 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALKER | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP, MN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MACKE | ||||||||
| OtherFirstName: | JAMIE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ARNP, MN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 959 | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989070959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095754084 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 220 W 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | ELLENSBURG | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989263060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099259861 | ||||||||
| FaxNumber: | 5092256313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2006 | ||||||||
| LastUpdateDate: | 11/06/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN00139973 | WA | N | Nursing Service Providers | Registered Nurse | 363LP0808X | AP60340233 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1710058839 | 05 | WA | MEDICAID |