Individual
DR. JENNIFER WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
2550 E GUADALUPE RD, #115, GILBERT, AZ 85234-5114
(480) 632-1544
(480) 632-1533
Mailing address
6301 S MCCLINTOCK DR, #101, TEMPE, AZ 85283-3392
(480) 214-2300
(480) 214-2301
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
31229
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00024623
BANNER HEALTH PLAN
AZ
01
—
031229
MAYO INSURANCE
AZ
01
—
1Z9881
HEALTHNET
AZ
05
—
831124
—
AZ
01
—
8311240
DEPT. OF ECONOMIC SECURIT
AZ
01
—
AZ0734620
BLUE CROSS BLUE SHIELD
AZ
Enumeration date
01/24/2006
Last updated
07/08/2007
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