Provider Demographics
NPI:1013389113
Name:WALLACE, JENNIFER (MS, LPC, RPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS, LPC, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 SAMARITAN DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2535
Mailing Address - Country:US
Mailing Address - Phone:888-850-4891
Mailing Address - Fax:
Practice Address - Street 1:110 SAMARITAN DR
Practice Address - Street 2:SUITE 110
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2535
Practice Address - Country:US
Practice Address - Phone:888-850-4891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007671101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional