Individual
JACQUELINE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1364 CLIFTON RD NE, ATLANTA, GA 30322-6504
(404) 712-2000
Mailing address
1745 DERRY AVE SW, ATLANTA, GA 30310-1503
(978) 473-1576
Taxonomy
Speciality
Code
Description
License number
State
390200000X
Student in an Organized Health Care Education/Training Program
Primary
—
—
Other
Enumeration date
07/12/2024
Last updated
04/03/2025
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