Individual
JACOB WALLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
104 N PARK DR, FAYETTEVILLE, GA 30214-1645
(470) 944-5290
Mailing address
206 OXFORD RD, NEW ALBANY, MS 38652-3115
(662) 534-2227
(662) 534-2330
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
4879
TN
Other
Enumeration date
02/23/2022
Last updated
11/21/2024
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