Provider Demographics
NPI:1750766937
Name:WALLACE, JANNA (RADTI)
Entity type:Individual
Prefix:
First Name:JANNA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RADTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6387 MOTHER LODE DR SPC 78
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-8225
Mailing Address - Country:US
Mailing Address - Phone:530-409-4310
Mailing Address - Fax:
Practice Address - Street 1:6387 MOTHER LODE DR SPC 78
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-8225
Practice Address - Country:US
Practice Address - Phone:530-409-4310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)