Provider Demographics
NPI:1114794328
Name:WALLACE-JENKINS, TERRIE M
Entity Type:Individual
Prefix:MRS
First Name:TERRIE
Middle Name:M
Last Name:WALLACE-JENKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 E 200TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44119-1562
Mailing Address - Country:US
Mailing Address - Phone:440-903-9398
Mailing Address - Fax:
Practice Address - Street 1:709 RADFORD DR
Practice Address - Street 2:
Practice Address - City:RICHMOND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44143-1988
Practice Address - Country:US
Practice Address - Phone:440-903-9398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH342000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes342000000XTransportation ServicesTransportation Network Company