Provider Demographics
NPI:1942927090
Name:WALLACE, JENNIFER ANNE (LPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9503 OAK SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:WOODWAY
Mailing Address - State:TX
Mailing Address - Zip Code:76712-6401
Mailing Address - Country:US
Mailing Address - Phone:318-237-8237
Mailing Address - Fax:
Practice Address - Street 1:9503 OAK SPRINGS DR
Practice Address - Street 2:
Practice Address - City:WOODWAY
Practice Address - State:TX
Practice Address - Zip Code:76712-6401
Practice Address - Country:US
Practice Address - Phone:318-237-8237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX89792101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional