Healthcare Provider Details

I. General information

NPI: 1740158377
Provider Name (Legal Business Name): JYNUINE WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2025
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 LOCUST ST
MCKEESPORT PA
15132-2911
US

IV. Provider business mailing address

604 LOCUST ST
MCKEESPORT PA
15132-2911
US

V. Phone/Fax

Practice location:
  • Phone: 412-735-9440
  • Fax:
Mailing address:
  • Phone: 412-735-9440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: