Provider Demographics
NPI:1679983449
Name:WALLACE, JENNIFER LEE (MSW, LSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ORWIGSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17961-2217
Mailing Address - Country:US
Mailing Address - Phone:610-960-7658
Mailing Address - Fax:
Practice Address - Street 1:1 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FLEETWOOD
Practice Address - State:PA
Practice Address - Zip Code:19522-1323
Practice Address - Country:US
Practice Address - Phone:610-944-0445
Practice Address - Fax:610-944-8834
Is Sole Proprietor?:No
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW126587101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health