Healthcare Provider Details

I. General information

NPI: 1073831350
Provider Name (Legal Business Name): JIM WALLACE & ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2010
Last Update Date: 05/31/2025
Certification Date: 05/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 E 9TH ST STE 4
EDMOND OK
73034-5773
US

IV. Provider business mailing address

202 S WASHITA AVE
WYNNEWOOD OK
73098-7820
US

V. Phone/Fax

Practice location:
  • Phone: 405-665-4385
  • Fax: 405-665-6396
Mailing address:
  • Phone: 405-665-4385
  • Fax: 405-665-6396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MS. TERESA GALE RUE-WALLACE
Title or Position: OWNER/CEO/PRESIDENT/EXEC. DIRECTOR
Credential: MASTERS SCIENCE
Phone: 405-665-4385