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General NPI Number Information
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NPI Number | 1356968440
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Entity Type | Individual
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Provider Name | MS. JENNIFER WALLACE
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Gender | Female
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Dates
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Enumeration Date | 07/06/2020
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Last Update Date | 06/24/2025
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Provider Practice Location Address
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Address Line | 3123 FAIRVIEW AVE E STE 200
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City | SEATTLE
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State | WA
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Zip | 98102-3051
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Country | US
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Telephone | 480-685-7530
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Fax | 480-900-8853
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Provider Business Mailing Address
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Address Line | 3409 MCDOUGALL AVE STE 200
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City | EVERETT
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State | WA
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Zip | 98201-5040
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Country | US
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Telephone | 480-685-7530
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Fax | 480-900-8853
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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 | 156F00000X
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Taxonomy Name | Technician/Technologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 172A00000X
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Taxonomy Name | Driver
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License Number | WDL722Z7B13B
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License Number State | WA
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Taxonomy #3
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Taxonomy Code | 246RP1900X
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Taxonomy Name | Phlebotomy Technician
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License Number | PC61547365
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License Number State | WA
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Taxonomy #4
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Taxonomy Code | 247200000X
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Taxonomy Name | Other Technician
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License Number | 032016
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License Number State | AZ
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Taxonomy #5
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number | 03D2197602
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License Number State | AZ
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Taxonomy #7
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 03D2197602
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License Number State | AZ
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Taxonomy #8
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Taxonomy Code | 374U00000X
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Taxonomy Name | Home Health Aide
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License Number |
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License Number State | AZ
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Taxonomy #9
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Taxonomy Code | 374U00000X
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Taxonomy Name | Home Health Aide
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License Number | EXPERIENCED
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License Number State | AZ
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Taxonomy #10
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 1568068609
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License Number State | AZ
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