Individual
JONATHAN DAVID WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LOTR
Contact information
Practice address
870 HIGHWAY 516, HEFLIN, LA 71039-3726
(318) 614-5684
Mailing address
870 HIGHWAY 516, HEFLIN, LA 71039-3726
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
OTT.Z12243
LA
Other
Enumeration date
07/25/2022
Last updated
07/25/2022
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