Provider Demographics
NPI:1366602609
Name:WALLACE, JANE LAMBERT (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JANE
Middle Name:LAMBERT
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:145 E GLENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-3552
Mailing Address - Country:US
Mailing Address - Phone:931-552-4413
Mailing Address - Fax:
Practice Address - Street 1:2150 WILMA RUDOLPH BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-6675
Practice Address - Country:US
Practice Address - Phone:931-542-2168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNSP0000000552235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist