Juliana Elizabeth Wallace, MSW ACSW, CADC III

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

L4458 Issued in OR

Practice address

3181 SW Sam Jackson Park Rd
Portland, OR 97239-3011

Phone

(503) 545-9110

NPI assigned

Sep 21, 2007

Last updated

Mar 10, 2016By the provider in NPPES

Sex

Female

Sole proprietor

No

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

Specialties & licenses 4

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in OR

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

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

{
    "created_epoch": "1190332800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1457568000000",
    "number": "1568658680",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10649 NE 13TH AVE",
            "address_2": "#128",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972111557",
            "telephone_number": "503-545-9110"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3181 SW SAM JACKSON PARK RD",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972393011",
            "telephone_number": "503-545-9110"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "JULIANA",
        "middle_name": "ELIZABETH",
        "name_prefix": "Mrs.",
        "credential": "MSW ACSW, CADC III",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-09-21",
        "last_updated": "2016-03-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "104100000X",
            "taxonomy_group": "",
            "desc": "Social Worker",
            "state": "OR",
            "license": "L4458",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "OR",
            "license": "L4458",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1568401347",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Jennifer Lyn Wallace, MD
• Jessica M Wallace, CRNA
• Jessica Zoee Savage Wallace
• Jodi Wallace
• Joy Michelle Wallace, QMHA
• Kimberly Wallace, CADC 1
• Madison Wallace
• Mandi Danielle Wallace
• Mikelia Wallace, MT-BC
• Priscilla Jane Wallace, MD

• Clinical Social Worker in Portland, OR
• Providers in Portland, OR by specialty
• Clinical Social Worker in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 10, 2016; 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.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.