Provider Demographics
NPI:1053892679
Name:JAMISON, WALTER TENNYSON
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:TENNYSON
Last Name:JAMISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 MILLS AVE STE C
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4280
Mailing Address - Country:US
Mailing Address - Phone:864-214-3794
Mailing Address - Fax:864-233-8626
Practice Address - Street 1:500 MILLS AVE STE C
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4280
Practice Address - Country:US
Practice Address - Phone:864-214-3794
Practice Address - Fax:864-233-8626
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIHCP-0858253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care