Provider Demographics
NPI:1710609045
Name:WALLACE, JARRED E (RN)
Entity Type:Individual
Prefix:
First Name:JARRED
Middle Name:E
Last Name:WALLACE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4618 MEIGS AVE
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-1819
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4646 JOHN R ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1916
Practice Address - Country:US
Practice Address - Phone:313-576-4436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704321978163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency