Individual
MR. JASON DAVID WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
2214 CHESAPEAKE CV, JONESBORO, AR 72404-7104
(615) 618-6200
Mailing address
2616 GALLAWAY CV, JONESBORO, AR 72404-7827
(615) 618-6200
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
125806
AR
Other
Enumeration date
06/22/2020
Last updated
05/14/2025
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