Individual
JILL WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PT
Contact information
Practice address
W239N1812 ROCKWOOD DR STE 100, PHCMA INC., WAUKESHA, WI 53188-1113
(262) 523-0310
Mailing address
W239N1812 ROCKWOOD DR STE 100, PHCMA INC., WAUKESHA, WI 53188-1113
(262) 523-0310
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
10232
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
40432300
—
WI
Enumeration date
04/26/2006
Last updated
01/18/2012
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