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General NPI Number Information
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NPI Number | 1063291789
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Entity Type | Individual
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Provider Name | JORDAN JEHREE WALLACE PA-C
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Gender | Female
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Dates
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Enumeration Date | 09/22/2023
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Last Update Date | 09/15/2025
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Provider Practice Location Address
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Address Line | 5620 W MARKHAM ST
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City | LITTLE ROCK
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State | AR
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Zip | 72205-3327
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Country | US
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Telephone | 501-508-7163
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Fax | 501-203-9850
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Provider Business Mailing Address
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Address Line | PO BOX 749495
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City | ATLANTA
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State | GA
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Zip | 30374-9495
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Country | US
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Telephone | 855-963-2100
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Fax | 813-321-1296
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA-1208
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License Number State | AR
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA-1208
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License Number State | AR
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