Individual
JACOB WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
A.P.R.N
Contact information
Practice address
630 E 1400 N STE 135, LOGAN, UT 84341-2549
(435) 787-8146
(435) 787-8149
Mailing address
PO BOX 912042, ST GEORGE, UT 84791-2042
(435) 215-0230
(435) 986-7092
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
7205712-4405
UT
363LG0600X
Gerontology Nurse Practitioner
7205712-4405
UT
Other
Enumeration date
07/05/2024
Last updated
08/23/2024
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