MEDICARE: JENNIFER ANNE WALLACE LPC

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	101YP2500X	Professional Counselor	89792	TX

General Provider Information

NPI Number	:	1942927090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER ANNE WALLACE LPC

Provider Business Mailing Address
First Line	:	9503 OAK SPRINGS DR
Second Line	:
City	:	WOODWAY
State	:	TX
Zip	:	76712-6401
Country	:	US
Telephone Number	:	318-237-8237
Fax Number	:

Provider Business Practice Location Address
First Line	:	9503 OAK SPRINGS DR
Second Line	:
City	:	WOODWAY
State	:	TX
Zip	:	76712-6401
Country	:	US
Telephone Number	:	318-237-8237
Fax Number	:

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

Provider Enumeration Date	:	10/19/2022
Last Update Date	:	10/19/2022

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