1962454215 NPI number — JENNIFER L WALLACE MD

Table of content: JENNIFER L WALLACE MD (NPI 1962454215)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962454215 NPI number — JENNIFER L WALLACE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
JENNIFER
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1962454215
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 UNIVERSITY DR
Provider Second Line Business Mailing Address:
MC A410
Provider Business Mailing Address City Name:
HERSHEY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17033-2360
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-531-8521
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 HOPE DR
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
HERSHEY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17033-2086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-531-7300
Provider Business Practice Location Address Fax Number:
717-531-3527
Provider Enumeration Date:
05/16/2006

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:  MD073642L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0018580630001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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