Provider Demographics
NPI:1174088900
Name:WALLACE, JENNIFER LOUISE (CSW, QMHP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LOUISE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CSW, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24100 S ROCKERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-7422
Mailing Address - Country:US
Mailing Address - Phone:605-343-5422
Mailing Address - Fax:605-343-1411
Practice Address - Street 1:851 WEST ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-2516
Practice Address - Country:US
Practice Address - Phone:605-393-4278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD6674104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker