Individual
JENNIFER KATHERINE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
2660 E MAIN ST, SUITE 204, VENTURA, CA 93003-2893
(805) 643-7500
(805) 643-7501
Mailing address
2660 E MAIN ST, SUITE 204, VENTURA, CA 93003-2893
(805) 643-7500
(805) 643-7501
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA20925
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2826
PHYSICIAN ASSISTANT LICENSE
CO
01
—
PA20925
CA PHYSICIAN ASSISTANT LICENSE
CA
Enumeration date
09/02/2009
Last updated
09/08/2010
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