Individual
JESSE L WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
AG-ACNP
Contact information
Practice address
500 MARTHA JEFFERSON DR STE 505, CHARLOTTESVILLE, VA 22911-4668
(434) 654-5260
(434) 654-5261
Mailing address
500 MARTHA JEFFERSON DR STE 505, CHARLOTTESVILLE, VA 22911-4668
(434) 654-5260
(434) 654-5261
Taxonomy
Speciality
Code
Description
License number
State
207LC0200X
Critical Care Medicine (Anesthesiology) Physician
0024187479
VA
363LA2100X
Acute Care Nurse Practitioner
Primary
0024187479
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
NONE
NONE
—
Enumeration date
07/24/2023
Last updated
05/11/2026
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