Provider Demographics
NPI:1730154154
Name:WALLACE, JENNIFER LYN (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 SE DIVISION ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1099
Mailing Address - Country:US
Mailing Address - Phone:888-480-1115
Mailing Address - Fax:
Practice Address - Street 1:1235 SE DIVISION ST
Practice Address - Street 2:SUITE 208
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1099
Practice Address - Country:US
Practice Address - Phone:888-480-1115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24427207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR232919Medicaid
ORI02430Medicare UPIN