Provider Demographics
NPI:1912208620
Name:WALLACE, JODY PAMELA (MS, CGC)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:PAMELA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS, CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 INDUSTRIAL RD
Mailing Address - Street 2:SUITE 410
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-2396
Mailing Address - Country:US
Mailing Address - Phone:650-249-9090
Mailing Address - Fax:650-730-2276
Practice Address - Street 1:201 INDUSTRIAL RD
Practice Address - Street 2:SUITE 410
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-2396
Practice Address - Country:US
Practice Address - Phone:650-249-9090
Practice Address - Fax:650-730-2276
Is Sole Proprietor?:No
Enumeration Date:2010-11-11
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS