Individual
JESSICA M WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNA
Contact information
Practice address
3181 SW SAM JACKSON PARK RD, PORTLAND, OR 97239-3011
(503) 494-7641
(503) 494-4661
Mailing address
3181 SW SAM JACKSON PARK RD., MAIL CODE SJH-2, PORTLAND, OR 97239
(503) 494-4910
(503) 494-8368
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
202203218CRNA-PP
OR
367500000X
Certified Registered Nurse Anesthetist
AP61087180
WA
Other
Enumeration date
04/23/2020
Last updated
10/17/2022
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