Jacob Henry Wallace, MD

Primary specialty

Obstetrics & Gynecology PhysicianTaxonomy code 207V00000X

License

2025027770 Issued in MO

Practice address

401 Holly Hills Ave
Saint Louis, MO 63111-2410

Phone

(314) 353-5190

Fax

(314) 353-7631

NPI assigned

Mar 22, 2021

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in MO

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Obstetrics/Gynecology

Education

Other, 2021

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Family Care Health CentersGroup PAC ID 7911815097, 53 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Interoperability endpoints

• FHIR API: https://epicproxy.et0965.epichosted.com/FHIRProxy/api/FHIR/DSTU2/

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Family Care Health Centers

  • Federally Qualified Health Center (FQHC)
  • Saint Louis, MO
  • NPI 1508867508
  Medicare reassignment Care Compare group NPD
• Family Care Health Centers

  • Federally Qualified Health Center (FQHC)
  • Saint Louis, MO
  • NPI 1023285624
  NPD
• Barnes Jewish Hospital

  • General Acute Care Hospital
  • Saint Louis, MO
  • NPI 1649299827
  NPD (past)
• SSM Health Care St. Louis

  • General Acute Care Hospital
  • Saint Louis, MO
  • NPI 1962572396
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1616371200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1751932800000",
    "number": "1124604061",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3990 BOWEN ST",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631163145",
            "telephone_number": "989-751-6079"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "401 HOLLY HILLS AVE",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631112410",
            "telephone_number": "314-353-5190",
            "fax_number": "314-353-7631"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "4352 Manchester Ave",
            "address_purpose": "LOCATION",
            "city": "Saint Louis",
            "state": "MO",
            "postal_code": "631102138",
            "country_code": "US",
            "telephone_number": "314-531-5444",
            "fax_number": "314-531-0063",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "JACOB",
        "middle_name": "HENRY",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-03-22",
        "last_updated": "2025-07-08",
        "certification_date": "2025-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "MO",
            "license": "2025027770",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Colleen Maire Wallace, MD
• Darcie L Wallace, PA-C
• Erin Wallace
• Francene Wallace
• Gretchen Coleman Wallace, MS, RD, LD, CD
• James Wallace, MA, THM, STM
• Jorge Wallace, PLPC
• Joslyn Wallace
• Kaila Wallace, DOULA
• Keith Alan Wallace, BS PHARM

• Obstetrics & Gynecology Physician in Saint Louis, MO
• Providers in Saint Louis, MO by specialty
• Obstetrics & Gynecology Physician in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.