Provider Demographics
NPI:1932855871
Name:WALLACE, JESSICA M (LPC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S5564 COUNTY RD S
Mailing Address - Street 2:
Mailing Address - City:VIOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54664-8058
Mailing Address - Country:US
Mailing Address - Phone:920-309-3040
Mailing Address - Fax:
Practice Address - Street 1:414 S EAST AVE
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-2006
Practice Address - Country:US
Practice Address - Phone:608-638-3332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-01
Last Update Date:2022-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5593125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health