Provider Demographics
NPI:1568650125
Name:WALLACE, JENNIFER LYNN (PT)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:LYNN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 N LIMESTONE ST
Mailing Address - Street 2:
Mailing Address - City:GAFFNEY
Mailing Address - State:SC
Mailing Address - Zip Code:29340-4735
Mailing Address - Country:US
Mailing Address - Phone:864-487-7874
Mailing Address - Fax:864-487-7659
Practice Address - Street 1:1445 N LIMESTONE ST
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29340-4735
Practice Address - Country:US
Practice Address - Phone:864-487-7874
Practice Address - Fax:864-487-7659
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5605225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist