Provider Demographics
NPI:1619364346
Name:WALLACE, JENNA E (PSYD)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:E
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2585 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-1642
Mailing Address - Country:US
Mailing Address - Phone:304-697-1396
Mailing Address - Fax:304-697-2086
Practice Address - Street 1:3729 TEAYS VALLEY RD
Practice Address - Street 2:STE 100
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9705
Practice Address - Country:US
Practice Address - Phone:304-760-6040
Practice Address - Fax:304-760-6042
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-21
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WV103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program