Individual
JENNIFER LYN WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1235 SE DIVISION ST, SUITE 208, PORTLAND, OR 97202-1099
(888) 480-1115
Mailing address
1235 SE DIVISION ST, SUITE 208, PORTLAND, OR 97202-1099
(888) 480-1115
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
MD24427
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
232919
—
OR
Enumeration date
02/20/2006
Last updated
03/18/2008
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