Active NPI
Jennifer Wallace, MS, LPC, RPT
- Professional Counselor
- Cumming, GA
National Provider Identifier
1013389113
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Professional Counselor
- License
- LPC007671
- Practice address
- 110 Samaritan Dr
Suite 110
Cumming, GA 30040-2535 - Phone
- (888) 850-4891
- NPI assigned
- Oct 28, 2015
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Professional Counselor | 101YP2500X | LPC007671 | GA | Primary |
Addresses
Primary practice location
110 Samaritan Dr
Suite 110
Cumming, GA 30040-2535
Mailing address
110 Samaritan Dr
Suite 110
Cumming, GA 30040-2535
Phone (888) 850-4891
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Mar 7, 2024 through Mar 7, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Master of Science
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| LPC007671 | GA | MD | Professional Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1445990400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1445990400000",
"number": "1013389113",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "110 SAMARITAN DR",
"address_2": "SUITE 110",
"city": "CUMMING",
"state": "GA",
"postal_code": "300402535",
"telephone_number": "888-850-4891"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "110 SAMARITAN DR",
"address_2": "SUITE 110",
"city": "CUMMING",
"state": "GA",
"postal_code": "300402535",
"telephone_number": "888-850-4891"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "JENNIFER",
"credential": "MS, LPC, RPT",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2015-10-28",
"last_updated": "2015-10-28",
"status": "A"
},
"taxonomies": [
{
"code": "101YP2500X",
"taxonomy_group": "",
"desc": "Counselor, Professional",
"state": "GA",
"license": "LPC007671",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Cumming, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 28, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.