Provider Demographics
NPI:1780417824
Name:WALLACE, JAILYN
Entity type:Individual
Prefix:
First Name:JAILYN
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1123
Mailing Address - Country:US
Mailing Address - Phone:707-391-1752
Mailing Address - Fax:
Practice Address - Street 1:626 MADISON AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-1123
Practice Address - Country:US
Practice Address - Phone:707-391-1752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-23
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator