Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1023553948 |
---|---|
Provider Name | Jake Alexander Walker |
First Address | North Hills, CA 91343-5117 |
Second Address | North Hills, CA 91343-5117 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/01/2017 |
Last Update Date | 01/01/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
#95-2633765 | MEDI-CAL (01) | CA |