Healthcare Provider Details

I. General information

NPI: 1285911032
Provider Name (Legal Business Name): JEANNE M WALLACE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2011
Last Update Date: 11/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1697 E 3450 N
NORTH LOGAN UT
84341-8310
US

IV. Provider business mailing address

1697 EAST 3450 NORTH
NORTH LOGAN UT
84341
US

V. Phone/Fax

Practice location:
  • Phone: 435-563-0053
  • Fax: 435-538-8058
Mailing address:
  • Phone: 435-563-0053
  • Fax: 435-538-8058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: