Provider Demographics
NPI:1124604061
Name:WALLACE, JACOB (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 LAMBETH CIR APT 208
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-4587
Mailing Address - Country:US
Mailing Address - Phone:989-751-6079
Mailing Address - Fax:
Practice Address - Street 1:6420 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1811
Practice Address - Country:US
Practice Address - Phone:314-768-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program