Healthcare Provider Details

I. General information

NPI: 1528994050
Provider Name (Legal Business Name): JENNIFER WALLACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 RESERVOIR RD NW
WASHINGTON DC
20007-2111
US

IV. Provider business mailing address

3700 RESERVOIR RD NW
WASHINGTON DC
20007-2111
US

V. Phone/Fax

Practice location:
  • Phone: 516-368-2522
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberR255355
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: