Basic Information
| Provider Information | |||||||||
| NPI: | 1811058431 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | JO | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHD, LMFT, ATR-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3750 SCOTT ST | ||||||||
| Address2: | APT 303 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941231179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6504837831 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2166 UNION ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941234004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6506173800 | ||||||||
| FaxNumber: | 6506880206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 04/10/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 43134 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 103G00000X | 26254 | CA | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103T00000X | PSY26254 | CA | N | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.