Healthcare Provider Details

I. General information

NPI: 1063291789
Provider Name (Legal Business Name): JORDAN JEHREE WALLACE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2023
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5620 W MARKHAM ST
LITTLE ROCK AR
72205-3327
US

IV. Provider business mailing address

PO BOX 749495
ATLANTA GA
30374-9495
US

V. Phone/Fax

Practice location:
  • Phone: 501-508-7163
  • Fax: 501-203-9850
Mailing address:
  • Phone: 855-963-2100
  • Fax: 813-321-1296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-1208
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1208
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: