Individual
JACKIE WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CRPA
Contact information
Practice address
2069 HUDSON AVE., D, ROCHESTER, NY 14617
(585) 694-1307
Mailing address
150 MT.HOPE AVE, ROCHESTER, NY 14620
(585) 706-7983
Taxonomy
Speciality
Code
Description
License number
State
175T00000X
Peer Specialist
Primary
—
NY
Other
Enumeration date
08/06/2025
Last updated
08/06/2025
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