Individual
JAKE TYLER WALLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
100 WALMART DR STE 5, MORRILTON, AR 72110-4525
(501) 477-2202
(501) 421-0543
Mailing address
2100 W MAIN ST, RUSSELLVILLE, AR 72801-2758
(479) 968-2525
(479) 968-2539
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
—
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
215702721
—
AR
Enumeration date
07/27/2016
Last updated
07/14/2025
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