Provider Demographics
NPI:1861853269
Name:WALLACE, JOLENE C (COMS)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:C
Last Name:WALLACE
Suffix:
Gender:F
Credentials:COMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 APPLE HOUSE LN
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-3324
Mailing Address - Country:US
Mailing Address - Phone:406-360-9480
Mailing Address - Fax:406-549-3581
Practice Address - Street 1:110 APPLE HOUSE LN
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-3324
Practice Address - Country:US
Practice Address - Phone:406-360-9480
Practice Address - Fax:406-549-3581
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225CX0006XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorOrientation and Mobility Training Provider