Provider Demographics
NPI:1427604248
Name:WALLACE, JESSICA MARIE (MA, LMHCA, NCC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MA, LMHCA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 GEORGE WASHINGTON WAY STE 8
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-4247
Mailing Address - Country:US
Mailing Address - Phone:509-676-6735
Mailing Address - Fax:
Practice Address - Street 1:750 GEORGE WASHINGTON WAY STE 8
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-4247
Practice Address - Country:US
Practice Address - Phone:509-676-6735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61280794101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health