Individual
MS. JENNIFER WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
3409 MCDOUGALL AVE STE 200, EVERETT, WA 98201-5040
(480) 685-7530
(480) 900-8853
Mailing address
3409 MCDOUGALL AVE STE 200, EVERETT, WA 98201-5040
(480) 685-7530
(480) 900-8853
Taxonomy
Speciality
Code
Description
License number
State
156F00000X
Technician/Technologist
—
—
172A00000X
Driver
WDL722Z7B13B
WA
246RP1900X
Phlebotomy Technician
PC61547365
WA
246RP1900X
Phlebotomy Technician
Primary
—
—
247200000X
Other Technician
032016
AZ
251E00000X
Home Health Agency
—
—
251J00000X
Nursing Care Agency
03D2197602
AZ
261Q00000X
Clinic/Center
—
—
261QH0100X
Health Service Clinic/Center
—
—
291U00000X
Clinical Medical Laboratory
03D2197602
AZ
291U00000X
Clinical Medical Laboratory
1568068609
AZ
374U00000X
Home Health Aide
EXPERIENCED
AZ
374U00000X
Home Health Aide
—
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
50D2322596
CLIA
WA
01
—
MTSW.FS.61686172
MEDICAL TEST SITE CLIA
WA
01
—
PC61547365
PHLEBOTOMY LICENSE
WA
Enumeration date
07/06/2020
Last updated
04/14/2026
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