Individual
JACKYLIN JILL WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
2731 NUGGET AVE, LAKE ISABELLA, CA 93240-9456
(760) 379-3412
(760) 379-5332
Mailing address
PO BOX 2632, LAKE ISABELLA, CA 93240-2632
(760) 379-3412
(760) 379-5332
Taxonomy
Speciality
Code
Description
License number
State
172V00000X
Community Health Worker
Primary
—
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
172V00000X
—
CA
Enumeration date
07/15/2022
Last updated
08/15/2023
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