Healthcare Provider Details

I. General information

NPI: 1386809697
Provider Name (Legal Business Name): MR. JACOB WALLACE II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2008
Last Update Date: 07/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4368 LINCOLN AVE
OAKLAND CA
94602-2529
US

IV. Provider business mailing address

3419 69TH AVE APT 102
OAKLAND CA
94605-2574
US

V. Phone/Fax

Practice location:
  • Phone: 510-531-3111
  • Fax: 510-530-8083
Mailing address:
  • Phone: 510-569-2552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: