Provider Demographics
NPI:1215581293
Name:WALLACE, JESSICA LYNNE (NNP-BC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNNE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NNP-BC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNNE
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:405 SE 17TH CT
Mailing Address - Street 2:
Mailing Address - City:GRIMES
Mailing Address - State:IA
Mailing Address - Zip Code:50111-6605
Mailing Address - Country:US
Mailing Address - Phone:319-899-9473
Mailing Address - Fax:
Practice Address - Street 1:1200 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1453
Practice Address - Country:US
Practice Address - Phone:515-241-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAK155915363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care