Healthcare Provider Details

I. General information

NPI: 1619364346
Provider Name (Legal Business Name): JENNA E WALLACE PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2015
Last Update Date: 04/08/2022
Certification Date: 04/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3729 TEAYS VALLEY RD STE 100
HURRICANE WV
25526-9705
US

IV. Provider business mailing address

2585 3RD AVE
HUNTINGTON WV
25703-1642
US

V. Phone/Fax

Practice location:
  • Phone: 304-760-6040
  • Fax: 304-760-6042
Mailing address:
  • Phone: 304-697-1396
  • Fax: 304-697-2086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: