Healthcare Provider Details

I. General information

NPI: 1326943614
Provider Name (Legal Business Name): JESSICA MARIE WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 FORT CLARKE DR
BENWOOD WV
26031-1375
US

IV. Provider business mailing address

25 FORT CLARKE DR
BENWOOD WV
26031-1375
US

V. Phone/Fax

Practice location:
  • Phone: 304-238-8390
  • Fax:
Mailing address:
  • Phone: 304-234-3570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: