Provider Demographics
NPI:1750544169
Name:WALLACE, JAMELIA
Entity type:Individual
Prefix:
First Name:JAMELIA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 S RODNEY PARHAM RD
Mailing Address - Street 2:APT 34G
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-4881
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4300 W 7TH STREET
Practice Address - Street 2:CENTRAL ARKANSAS VETERANS HOSPITAL
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205
Practice Address - Country:US
Practice Address - Phone:501-257-1484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator