Healthcare Provider Details

I. General information

NPI: 1659637478
Provider Name (Legal Business Name): JESSICA LYNN WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2012
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26652 MUSE ROAD
MUSE OK
74949
US

IV. Provider business mailing address

BOX 26652 ST. HWY. 63
HODGEN OK
74939
US

V. Phone/Fax

Practice location:
  • Phone: 918-567-1719
  • Fax:
Mailing address:
  • Phone: 918-567-1719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: