Provider Demographics
NPI:1164852422
Name:WALLACE, JORGE (PLPC)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6532 BARTMER AVE
Mailing Address - Street 2:2E
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-2630
Mailing Address - Country:US
Mailing Address - Phone:314-299-5284
Mailing Address - Fax:
Practice Address - Street 1:6532 BARTMER AVE
Practice Address - Street 2:2E
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-2630
Practice Address - Country:US
Practice Address - Phone:314-299-5284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-22
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011039643101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional