Provider Demographics
NPI:1205883147
Name:WALLACE, JAMIE F
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:F
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:M
Other - Last Name:FLANDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:735 GLYNN ST S
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-2049
Mailing Address - Country:US
Mailing Address - Phone:770-461-4126
Mailing Address - Fax:770-461-8852
Practice Address - Street 1:735 GLYNN ST S
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-2049
Practice Address - Country:US
Practice Address - Phone:770-461-4126
Practice Address - Fax:770-461-8852
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043044208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00794483AMedicaid