Jennifer Wallace, SUDRC

Primary specialty

Addiction (Substance Use Disorder) CounselorTaxonomy code 101YA0400X

License

R1441130821 Issued in CA

Practice address

98 Hendley St
Santa Rosa, CA 95404-5025

Phone

(707) 527-0412

NPI assigned

Aug 17, 2021

Sex

Female

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

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.

• Women's Recovery Services

  • Children's Substance Abuse Rehabilitation Facility
  • Santa Rosa, CA
  • NPI 1154981785
  NPD (past)

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

{
    "created_epoch": "1629158400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1720483200000",
    "number": "1508532953",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1356",
            "city": "SANTA ROSA",
            "state": "CA",
            "postal_code": "954021356",
            "telephone_number": "707-527-0412"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "98 HENDLEY ST",
            "city": "SANTA ROSA",
            "state": "CA",
            "postal_code": "954045025",
            "telephone_number": "707-527-0412"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "JENNIFER",
        "credential": "SUDRC",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2021-08-17",
        "last_updated": "2024-07-09",
        "certification_date": "2024-07-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "CA",
            "license": "R1441130821",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "jenniferw@womensrecoveryservices.org",
            "affiliation": "N",
            "endpointDescription": "business email",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "98 Hendley St",
            "city": "Santa Rosa",
            "state": "CA",
            "country_code": "US",
            "postal_code": "954045025",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Kimberly Anne Walker - Demattei, LMFT
• Keamiyah Neishelle Walker, MSN, APRN,FNP-C
• Kevin Walker, MD
• Ryan Daniel Wall
• Christopher J Wallace, DDS
• John Nell Wallace
• Ava Wallen
• Kathleen Harms Walsh, F.N.P.
• Linda Therese Walsh, MFT
• Michael E. Walsh

• Addiction (Substance Use Disorder) Counselor in Santa Rosa, CA
• Providers in Santa Rosa, CA by specialty
• Addiction (Substance Use Disorder) Counselor in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.