Healthcare Provider Details

I. General information

NPI: 1790412591
Provider Name (Legal Business Name): JENNIFER MARIE WALLACE NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2022
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 CABOT CT
DEPTFORD NJ
08096-5114
US

IV. Provider business mailing address

36 WALKER RD
WEST ORANGE NJ
07052-4403
US

V. Phone/Fax

Practice location:
  • Phone: 856-885-4579
  • Fax:
Mailing address:
  • Phone: 973-715-5586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number26NJ01341100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: