Provider Demographics
NPI:1578796926
Name:WALLACE, JENNIFER KATHERINE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KATHERINE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2660 E MAIN ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-2893
Mailing Address - Country:US
Mailing Address - Phone:805-643-7500
Mailing Address - Fax:805-643-7501
Practice Address - Street 1:2660 E MAIN ST
Practice Address - Street 2:SUITE 204
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2893
Practice Address - Country:US
Practice Address - Phone:805-643-7500
Practice Address - Fax:805-643-7501
Is Sole Proprietor?:No
Enumeration Date:2009-09-02
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20925363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO2826OtherPHYSICIAN ASSISTANT LICENSE
CAPA20925OtherCA PHYSICIAN ASSISTANT LICENSE