Provider Demographics
NPI:1982416889
Name:WALLACE, JENNIFER MARIE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
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 1:6824 LOGUE LN
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-7241
Mailing Address - Country:US
Mailing Address - Phone:254-327-2001
Mailing Address - Fax:
Practice Address - Street 1:6824 LOGUE LN
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-7241
Practice Address - Country:US
Practice Address - Phone:254-327-2001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician