Provider Demographics
NPI:1790412591
Name:WALLACE, JENNIFER MARIE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 WALKER RD
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-4403
Mailing Address - Country:US
Mailing Address - Phone:973-715-5586
Mailing Address - Fax:
Practice Address - Street 1:202 CABOT CT
Practice Address - Street 2:
Practice Address - City:DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08096-5114
Practice Address - Country:US
Practice Address - Phone:856-885-4579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01341100363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology