MEDICARE: JESSICA LYNN 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
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1659637478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LYNN WALLACE

Provider Business Mailing Address
First Line	:	BOX 26652 ST. HWY. 63
Second Line	:
City	:	HODGEN
State	:	OK
Zip	:	74939
Country	:	US
Telephone Number	:	918-567-1719
Fax Number	:

Provider Business Practice Location Address
First Line	:	26652 MUSE ROAD
Second Line	:
City	:	MUSE
State	:	OK
Zip	:	74949
Country	:	US
Telephone Number	:	918-567-1719
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2012
Last Update Date	:	04/05/2012

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