1912977885 NPI number — DR. JENNIFER WALLACE M.D.

Table of content: DR. JENNIFER WALLACE M.D. (NPI 1912977885)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912977885 NPI number — DR. JENNIFER WALLACE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
JENNIFER
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912977885
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6301 S MCCLINTOCK DR
Provider Second Line Business Mailing Address:
#101
Provider Business Mailing Address City Name:
TEMPE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85283-3392
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-214-2300
Provider Business Mailing Address Fax Number:
480-214-2301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2550 E GUADALUPE RD
Provider Second Line Business Practice Location Address:
#115
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85234-5114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-632-1544
Provider Business Practice Location Address Fax Number:
480-632-1533
Provider Enumeration Date:
01/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  31229 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 031229 . This is a "MAYO INSURANCE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 8311240 . This is a "DEPT. OF ECONOMIC SECURIT" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 831124 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: AZ0734620 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 1Z9881 . This is a "HEALTHNET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 00024623 . This is a "BANNER HEALTH PLAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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