Provider Demographics
NPI:1689846164
Name:WALLACE, JESSICA NICOLE (RN)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:NICOLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:NICOLE
Other - Last Name:CALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:655 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:45760
Mailing Address - Country:US
Mailing Address - Phone:740-416-5643
Mailing Address - Fax:
Practice Address - Street 1:655 FRONT ST
Practice Address - Street 2:
Practice Address - City:MIDDLEPORT
Practice Address - State:OH
Practice Address - Zip Code:45760
Practice Address - Country:US
Practice Address - Phone:740-416-5643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSL987156163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse