Provider Demographics
NPI:1306035431
Name:WALLACE, JENNIFER L (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3891 50TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33711-4811
Mailing Address - Country:US
Mailing Address - Phone:630-554-4701
Mailing Address - Fax:
Practice Address - Street 1:3891 50TH AVE S
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-4811
Practice Address - Country:US
Practice Address - Phone:630-554-4701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22282225100000X
IL070.009079225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist