Healthcare Provider Details

I. General information

NPI: 1356968440
Provider Name (Legal Business Name): MS. JENNIFER WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2020
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3409 MCDOUGALL AVE STE 200
EVERETT WA
98201-5040
US

IV. Provider business mailing address

3409 MCDOUGALL AVE STE 200
EVERETT WA
98201-5040
US

V. Phone/Fax

Practice location:
  • Phone: 480-685-7530
  • Fax: 480-900-8853
Mailing address:
  • Phone: 480-685-7530
  • Fax: 480-900-8853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number1568068609
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License NumberPC61547365
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberEXPERIENCED
License Number StateAZ
# 6
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateAZ
# 8
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number032016
License Number StateAZ
# 9
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number03D2197602
License Number StateAZ
# 10
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number03D2197602
License Number StateAZ
# 11
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License NumberWDL722Z7B13B
License Number StateWA
# 12
Primary TaxonomyN
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State
# 13
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: