Provider Demographics
NPI:1285031682
Name:WALLACE, JESSICA
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:WALLACE
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 1:14277 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:OH
Mailing Address - Zip Code:44609-9504
Mailing Address - Country:US
Mailing Address - Phone:330-938-1122
Mailing Address - Fax:
Practice Address - Street 1:2900 KNOX SCHOOL RD
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-9021
Practice Address - Country:US
Practice Address - Phone:330-938-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2015123235Z00000X
OHSP.12089235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist