Provider Demographics
NPI:1568590396
Name:WALLIS, JESSICA RENE
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:RENE
Last Name:WALLIS
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 1:65 RIDGE RD
Mailing Address - Street 2:APT. B-15
Mailing Address - City:WAVERLY
Mailing Address - State:TN
Mailing Address - Zip Code:37185-2000
Mailing Address - Country:US
Mailing Address - Phone:931-299-7014
Mailing Address - Fax:
Practice Address - Street 1:805 N CHARLOTTE ST
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-1008
Practice Address - Country:US
Practice Address - Phone:615-441-6074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider