Provider Demographics
NPI:1174379093
Name:WALLACE, JESSICA R (RN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5106 BARKER RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45118-9717
Mailing Address - Country:US
Mailing Address - Phone:740-851-2022
Mailing Address - Fax:
Practice Address - Street 1:953 S SOUTH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2921
Practice Address - Country:US
Practice Address - Phone:937-383-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-30
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.503064163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse