Provider Demographics
NPI:1437710787
Name:WALLACE, JESSICA GENSLER (DNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:GENSLER
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 E OHIO ST APT 1510
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4047
Mailing Address - Country:US
Mailing Address - Phone:612-986-5139
Mailing Address - Fax:
Practice Address - Street 1:225 E CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:312-227-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.019552363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics