Healthcare Provider Details

I. General information

NPI: 1780210658
Provider Name (Legal Business Name): JORDAN SCOTT WALLACE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2020
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9801 FRONTIER AVE SE
SNOQUALMIE WA
98065-5200
US

IV. Provider business mailing address

9801 FRONTIER AVE SE
SNOQUALMIE WA
98065-5200
US

V. Phone/Fax

Practice location:
  • Phone: 425-831-2300
  • Fax:
Mailing address:
  • Phone: 425-831-2300
  • Fax: 425-396-7694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD61570069
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: