Provider Demographics
NPI:1023526050
Name:WALTERS, JENNIFER (MA, LAT, ATC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:MA, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5155 SADDLE DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-7698
Mailing Address - Country:US
Mailing Address - Phone:765-585-5977
Mailing Address - Fax:
Practice Address - Street 1:2362 E STATE ROAD 18
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IN
Practice Address - Zip Code:46929-8201
Practice Address - Country:US
Practice Address - Phone:574-967-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-11
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001786A2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine