Provider Demographics
NPI:1154202901
Name:WALLACE, JESSICA FAE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:FAE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:FAE
Other - Last Name:KLINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RDH, PHDH, EFDA
Mailing Address - Street 1:2200 FLICKER LN
Mailing Address - Street 2:
Mailing Address - City:ROLLING MEADOWS
Mailing Address - State:IL
Mailing Address - Zip Code:60008-1317
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 FLICKER LN
Practice Address - Street 2:
Practice Address - City:ROLLING MEADOWS
Practice Address - State:IL
Practice Address - Zip Code:60008-1317
Practice Address - Country:US
Practice Address - Phone:815-830-4739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-09
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL002017626124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty