Provider Demographics
NPI:1619561321
Name:WALLACE, JESSICA BOWMAN (NP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:BOWMAN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 TURNER MCCALL BLVD SW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-5621
Mailing Address - Country:US
Mailing Address - Phone:706-509-6110
Mailing Address - Fax:706-509-6101
Practice Address - Street 1:253 COUNTY ROAD 766
Practice Address - Street 2:
Practice Address - City:CEDAR BLUFF
Practice Address - State:AL
Practice Address - Zip Code:35959-3595
Practice Address - Country:US
Practice Address - Phone:256-899-9147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN241671363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily