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NPI Code Detail

MEDICARE: JACOB WALLACE

MEDICARE: JACOB WALLACE
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1639031503
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACOB WALLACE
Provider Business Mailing Address
First Line : 15175 SW 111TH ST
Second Line :
City : MIAMI
State : FL
Zip : 33196-2503
Country : US
Telephone Number : 786-209-4513
Fax Number :
Provider Business Practice Location Address
First Line : 15924 SW 92ND AVE
Second Line :
City : PALMETTO BAY
State : FL
Zip : 33157-1842
Country : US
Telephone Number : 305-964-5824
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/01/2025
Last Update Date : 12/01/2025

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Directions to “ JACOB WALLACE ” Practice Location

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