Provider Demographics
NPI:1356672638
Name:WALLIS, JESSIE LIN
Entity Type:Individual
Prefix:MS
First Name:JESSIE
Middle Name:LIN
Last Name:WALLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JESSIE
Other - Middle Name:LIN
Other - Last Name:STONECIPHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:501 W GENESEE ST
Mailing Address - Street 2:APT 38
Mailing Address - City:CHITTENANGO
Mailing Address - State:NY
Mailing Address - Zip Code:13037-1071
Mailing Address - Country:US
Mailing Address - Phone:315-361-9131
Mailing Address - Fax:315-361-4526
Practice Address - Street 1:1019 NORTHSIDE SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-4901
Practice Address - Country:US
Practice Address - Phone:315-361-9131
Practice Address - Fax:315-361-4526
Is Sole Proprietor?:No
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator