Individual
JARRED E WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
RN
Contact information
Practice address
4646 JOHN R ST, DETROIT, MI 48201-1916
(313) 576-4436
Mailing address
4618 MEIGS AVE, WATERFORD, MI 48329-1819
Taxonomy
Speciality
Code
Description
License number
State
163WE0003X
Emergency Registered Nurse
Primary
4704321978
MI
Other
Enumeration date
09/14/2022
Last updated
10/18/2022
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