Provider Demographics
NPI:1356968440
Name:WALLACE, JENNIFER
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3409 MCDOUGALL AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-5040
Mailing Address - Country:US
Mailing Address - Phone:480-685-7530
Mailing Address - Fax:480-900-8853
Practice Address - Street 1:3123 FAIRVIEW AVE E STE 200
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-3051
Practice Address - Country:US
Practice Address - Phone:480-685-7530
Practice Address - Fax:480-900-8853
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-06
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWDL722Z7B13B172A00000X
156F00000X
WAPC61547365246RP1900X
AZ032016247200000X
AZ03D2197602251J00000X, 291U00000X
AZ374U00000X
AZEXPERIENCED374U00000X
AZ1568068609291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No172A00000XOther Service ProvidersDriver
No156F00000XEye and Vision Services ProvidersTechnician/Technologist
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No251J00000XAgenciesNursing Care
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMTSW.FS.61686172OtherMEDICAL TEST SITE CLIA
AZ03D2197602OtherCLIA
WAPC61547365OtherPHLEBOTOMY LICENSE