Provider Demographics
NPI:1659637478
Name:WALLACE, JESSICA LYNN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:WALLACE
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:BOX 26652 ST. HWY. 63
Mailing Address - Street 2:
Mailing Address - City:HODGEN
Mailing Address - State:OK
Mailing Address - Zip Code:74939
Mailing Address - Country:US
Mailing Address - Phone:918-567-1719
Mailing Address - Fax:
Practice Address - Street 1:26652 MUSE ROAD
Practice Address - Street 2:
Practice Address - City:MUSE
Practice Address - State:OK
Practice Address - Zip Code:74949
Practice Address - Country:US
Practice Address - Phone:918-567-1719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health