Provider Demographics
NPI:1508437534
Name:WALLACE, JACQUELINE VASQUEZ
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:VASQUEZ
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 SE MILLER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-6380
Mailing Address - Country:US
Mailing Address - Phone:503-888-2114
Mailing Address - Fax:
Practice Address - Street 1:1015 SE MILLER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-6380
Practice Address - Country:US
Practice Address - Phone:503-888-2114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter