Provider Demographics
NPI:1700864493
Name:WALLACE, JENNIFER LEA (PAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 6TH AVE S
Mailing Address - Street 2:SUITE 385
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4662
Mailing Address - Country:US
Mailing Address - Phone:727-553-7100
Mailing Address - Fax:727-553-7198
Practice Address - Street 1:625 6TH AVE S
Practice Address - Street 2:SUITE 385
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4662
Practice Address - Country:US
Practice Address - Phone:727-553-7100
Practice Address - Fax:727-553-7198
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105134363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ54100Medicare UPIN
ILK21619Medicare PIN
IL501100Medicare ID - Type UnspecifiedGROUP MEDICARE COOK
ILK21619Medicare PIN