Provider Demographics
NPI:1912977885
Name:WALLACE, JENNIFER (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:6301 S MCCLINTOCK DR
Mailing Address - Street 2:#101
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-3392
Mailing Address - Country:US
Mailing Address - Phone:480-214-2300
Mailing Address - Fax:480-214-2301
Practice Address - Street 1:2550 E GUADALUPE RD
Practice Address - Street 2:#115
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-5114
Practice Address - Country:US
Practice Address - Phone:480-632-1544
Practice Address - Fax:480-632-1533
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ31229208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ031229OtherMAYO INSURANCE
AZ8311240OtherDEPT. OF ECONOMIC SECURIT
AZ831124Medicaid
AZAZ0734620OtherBLUE CROSS BLUE SHIELD
AZ1Z9881OtherHEALTHNET
AZ00024623OtherBANNER HEALTH PLAN