Provider Demographics
NPI:1235682238
Name:WALLIS, JAKE TYLER
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:TYLER
Last Name:WALLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:TYLER
Other - Last Name:WALLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPT
Mailing Address - Street 1:2100 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2758
Mailing Address - Country:US
Mailing Address - Phone:479-968-2525
Mailing Address - Fax:479-968-2539
Practice Address - Street 1:100 WALMART DR STE 5
Practice Address - Street 2:
Practice Address - City:MORRILTON
Practice Address - State:AR
Practice Address - Zip Code:72110-4525
Practice Address - Country:US
Practice Address - Phone:501-477-2202
Practice Address - Fax:501-421-0543
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR215702721Medicaid