Provider Demographics
NPI:1487651147
Name:WALLACE, JANEEN LOUISE (DC)
Entity Type:Individual
Prefix:DR
First Name:JANEEN
Middle Name:LOUISE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6610 E BASELINE RD
Mailing Address - Street 2:STE 103
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4441
Mailing Address - Country:US
Mailing Address - Phone:480-245-4995
Mailing Address - Fax:
Practice Address - Street 1:6610 E BASELINE RD
Practice Address - Street 2:STE 103
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4441
Practice Address - Country:US
Practice Address - Phone:480-245-4995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7558111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU87069Medicare UPIN
AZZ141374Medicare UPIN
AZ101592Medicare PIN