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General NPI Number Information
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NPI Number | 1659637478
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Entity Type | Individual
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Provider Name | JESSICA LYNN WALLACE
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Gender | Female
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Dates
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Enumeration Date | 04/05/2012
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Last Update Date | 04/05/2012
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Provider Practice Location Address
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Address Line | 26652 MUSE ROAD
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City | MUSE
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State | OK
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Zip | 74949
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Country | US
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Telephone | 918-567-1719
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Fax |
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Provider Business Mailing Address
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Address Line | BOX 26652 ST. HWY. 63
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City | HODGEN
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State | OK
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Zip | 74939
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Country | US
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Telephone | 918-567-1719
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Fax |
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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 | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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