Provider Demographics
NPI:1750679056
Name:WALLACE, JANEEN E (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JANEEN
Middle Name:E
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 EL CAMINO REAL
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1530
Mailing Address - Country:US
Mailing Address - Phone:650-559-0011
Mailing Address - Fax:650-559-0012
Practice Address - Street 1:5050 EL CAMINO REAL
Practice Address - Street 2:SUITE 210
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94022-1530
Practice Address - Country:US
Practice Address - Phone:650-559-0011
Practice Address - Fax:650-559-0012
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37914225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFN854ZMedicare PIN
CA1053320325OtherGROUP NPI