Provider Demographics
NPI:1093927907
Name:WALLACE, JENNIFER M (MED)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:MRS
Other - First Name:GENEVA
Other - Middle Name:M
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MED
Mailing Address - Street 1:2298 W HORIZON RIDGE PKWY
Mailing Address - Street 2:SUITE 109
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-2696
Mailing Address - Country:US
Mailing Address - Phone:702-363-7284
Mailing Address - Fax:702-242-5252
Practice Address - Street 1:2298 W HORIZON RIDGE PKWY
Practice Address - Street 2:SUITE 109
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-2696
Practice Address - Country:US
Practice Address - Phone:702-363-7284
Practice Address - Fax:702-242-5252
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1118L101YA0400X
NV00561-A104100000X
NVR05387106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist