Provider Demographics
NPI:1710324165
Name:WALLACE, JASMINE RENEE'
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:RENEE'
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 1:5535 NW CACHE RD
Mailing Address - Street 2:APT:8G
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-3336
Mailing Address - Country:US
Mailing Address - Phone:580-713-9316
Mailing Address - Fax:
Practice Address - Street 1:5535 NW CACHE RD
Practice Address - Street 2:APT:8G
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-3336
Practice Address - Country:US
Practice Address - Phone:580-713-9316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-24
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor