Provider Demographics
NPI:1972936425
Name:WALLACE, JAN ELLEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JAN
Middle Name:ELLEN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 N TUCSON BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-4740
Mailing Address - Country:US
Mailing Address - Phone:520-396-1021
Mailing Address - Fax:520-881-1648
Practice Address - Street 1:140 N TUCSON BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-4740
Practice Address - Country:US
Practice Address - Phone:520-396-1021
Practice Address - Fax:520-881-1648
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-16471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical