Provider Demographics
NPI:1124909254
Name:WALLACE, JENNIFER MARLENE (LMHC)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MARLENE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:IL
Mailing Address - Zip Code:62441-1426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 E PUGH DR STE 7
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-3942
Practice Address - Country:US
Practice Address - Phone:217-712-9347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health