Provider Demographics
NPI:1639915911
Name:WALLACE, JACOB (APRN)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 912042
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84791-2042
Mailing Address - Country:US
Mailing Address - Phone:435-215-0230
Mailing Address - Fax:435-986-7092
Practice Address - Street 1:630 E 1400 N STE 135
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2549
Practice Address - Country:US
Practice Address - Phone:435-787-8146
Practice Address - Fax:435-787-8149
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-05
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7205712-4405363LG0600X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology