Basic Information
| Provider Information | |||||||||
| NPI: | 1912977885 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6301 S MCCLINTOCK DR | ||||||||
| Address2: | #101 | ||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852833392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802142300 | ||||||||
| FaxNumber: | 4802142301 | ||||||||
| Practice Location | |||||||||
| Address1: | 2550 E GUADALUPE RD | ||||||||
| Address2: | #115 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852345114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806321544 | ||||||||
| FaxNumber: | 4806321533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 208000000X | 31229 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 031229 | 01 | AZ | MAYO INSURANCE | OTHER | 8311240 | 01 | AZ | DEPT. OF ECONOMIC SECURIT | OTHER | 831124 | 05 | AZ | MEDICAID | AZ0734620 | 01 | AZ | BLUE CROSS BLUE SHIELD | OTHER | 1Z9881 | 01 | AZ | HEALTHNET | OTHER | 00024623 | 01 | AZ | BANNER HEALTH PLAN | OTHER |