Individual
DR. JACOB HENRY WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
401 HOLLY HILLS AVE, SAINT LOUIS, MO 63111-2410
(314) 353-5190
(314) 353-7631
Mailing address
3990 BOWEN ST, SAINT LOUIS, MO 63116-3145
(989) 751-6079
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
Primary
2025027770
MO
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
03/22/2021
Last updated
07/08/2025
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