Individual
JESSICA LYNN WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
26652 MUSE ROAD, MUSE, OK 74949
(918) 567-1719
Mailing address
BOX 26652 ST. HWY. 63, HODGEN, OK 74939
(918) 567-1719
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
Other
Enumeration date
04/05/2012
Last updated
04/05/2012
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