Provider Demographics
NPI:1568118172
Name:WALLIS, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WALLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 OXFORD RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-3115
Mailing Address - Country:US
Mailing Address - Phone:662-534-2227
Mailing Address - Fax:662-534-2330
Practice Address - Street 1:6515 POPLAR AVE STE 106
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4878
Practice Address - Country:US
Practice Address - Phone:901-426-1090
Practice Address - Fax:901-426-1091
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4879363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant