Provider Demographics
NPI:1538557012
Name:WALLACE, JEFFREY EUGENE (LICSW, MSW, CDP, MHP)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:EUGENE
Last Name:WALLACE
Suffix:
Gender:M
Credentials:LICSW, MSW, CDP, MHP
Other - Prefix:
Other - First Name:JEFF
Other - Middle Name:
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:REV, MDIV
Mailing Address - Street 1:400 S JEFFERSON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-3143
Mailing Address - Country:US
Mailing Address - Phone:509-822-8662
Mailing Address - Fax:
Practice Address - Street 1:400 S JEFFERSON ST STE 200
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-3143
Practice Address - Country:US
Practice Address - Phone:509-822-8662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-06
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC604933191041C0700X, 101YM0800X
WACO60490069101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)