Jechell Lary-Waller, PMHNP

Key facts

NPI

1295548378

Entity type

Individual (NPI type 1)

Primary specialty

Psychiatric/Mental Health Nurse Practitioner 363LP0808X

License

RN15699 (GA)

Practice address

452 Graham Woods Cir
Gray, GA 31032-4914

Phone

(478) 390-3836

NPI assigned

Jan 31, 2025

Sex

Female

Sole proprietor

Yes

Medicare participation

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD)

No

State licenses

Specialties & licenses

Addresses

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Jul 24, 2025.

{
    "created_epoch": "1738281600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1753315200000",
    "number": "1295548378",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "452 GRAHAM WOODS CIR",
            "city": "GRAY",
            "state": "GA",
            "postal_code": "310324914",
            "telephone_number": "478-390-3836"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "452 GRAHAM WOODS CIR",
            "city": "GRAY",
            "state": "GA",
            "postal_code": "310324914",
            "telephone_number": "478-390-3836"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "4539 N 22nd St Ste R",
            "address_purpose": "LOCATION",
            "city": "Phoenix",
            "state": "AZ",
            "postal_code": "850164639",
            "country_code": "US",
            "telephone_number": "478-390-3836",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "LARY-WALLER",
        "first_name": "JECHELL",
        "credential": "PMHNP",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2025-01-31",
        "last_updated": "2025-07-24",
        "certification_date": "2025-07-24",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "GA",
            "license": "RN15699",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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All providers in Gray, GA · Psychiatric/Mental Health Nurse Practitioner in Georgia