Healthcare Provider Details

I. General information

NPI: 1639915911
Provider Name (Legal Business Name): JACOB WALLACE A.P.R.N
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2024
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 E 1400 N STE 135
LOGAN UT
84341-2549
US

IV. Provider business mailing address

PO BOX 912042
ST GEORGE UT
84791-2042
US

V. Phone/Fax

Practice location:
  • Phone: 435-787-8146
  • Fax: 435-787-8149
Mailing address:
  • Phone: 435-215-0230
  • Fax: 435-986-7092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7205712-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number7205712-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: