Provider Demographics
NPI:1942356308
Name:WALOS, JESSICA (PHD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WALOS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-3749
Mailing Address - Country:US
Mailing Address - Phone:262-719-3625
Mailing Address - Fax:262-567-5560
Practice Address - Street 1:436 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3749
Practice Address - Country:US
Practice Address - Phone:262-719-3625
Practice Address - Fax:262-567-5560
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2656103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39157700Medicaid
WI000344374Medicare PIN