Provider Demographics
NPI:1780210658
Name:WALLACE, JORDAN SCOTT (MD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:SCOTT
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9801 FRONTIER AVE SE
Mailing Address - Street 2:
Mailing Address - City:SNOQUALMIE
Mailing Address - State:WA
Mailing Address - Zip Code:98065-5200
Mailing Address - Country:US
Mailing Address - Phone:425-831-2300
Mailing Address - Fax:425-396-7694
Practice Address - Street 1:9801 FRONTIER AVE SE
Practice Address - Street 2:
Practice Address - City:SNOQUALMIE
Practice Address - State:WA
Practice Address - Zip Code:98065-5200
Practice Address - Country:US
Practice Address - Phone:425-831-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-22
Last Update Date:2025-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61570069208000000X, 208000000X
CAA188568208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist