Provider Demographics
NPI:1770219693
Name:WALLACE, JONATHAN DAVID (LOTR)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DAVID
Last Name:WALLACE
Suffix:
Gender:M
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 HIGHWAY 516
Mailing Address - Street 2:
Mailing Address - City:HEFLIN
Mailing Address - State:LA
Mailing Address - Zip Code:71039-3726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:870 HIGHWAY 516
Practice Address - Street 2:
Practice Address - City:HEFLIN
Practice Address - State:LA
Practice Address - Zip Code:71039-3726
Practice Address - Country:US
Practice Address - Phone:318-614-5684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z12243225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist