Jacob Wallace, A.P.R.N

Primary specialty

Family Nurse PractitionerTaxonomy code 363LF0000X

License

7205712-4405 Issued in UT

Practice address

630 E 1400 N Ste 135
Logan, UT 84341-2549

Phone

(435) 787-8146

Fax

(435) 787-8149

NPI assigned

Jul 5, 2024

Last updated

Aug 23, 2024By the provider in NPPES

Sex

Male

Sole proprietor

Yes

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 UT

Eligible to order & refer

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

Green means eligible to order or refer.

Enrollment records 1

Specialty

Nurse Practitioner

Education

Other, 2024

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Southwest Spine and Pain Care Specialists LLCGroup PAC ID 6406020049, 42 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Intermountain Health Logan Regional Hospital Hospital, Logan, UT, CCN 460015
• Bear River Valley Hospital Hospital, Tremonton, UT, CCN 460039

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: jacobwallace@ssapcsl-ut.direct.office.nextgen.com

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

• Southwest Spine and Pain Care Specialists, LLC

  dba Physician Laboratory Services

  • Pain Medicine (Anesthesiology) Physician
  • St George, UT
  • NPI 1144509985
  Medicare reassignment Care Compare group NPD
• Southwest Spine and Pain Care Specialists, LLC

  dba Vista Spine Sports and Injury Center

  • Chiropractor
  • St George, UT
  • NPI 1871263178
  NPD
• Rocky Mountain Dermatology Inc

  • Dermatology Physician
  • North Logan, UT
  • NPI 1154527372
  NPD (past)

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Ihc Health Services Inc

  dba Intermountain Health Bear River Valley Hospital

  • General Acute Care Hospital
  • Tremonton, UT
  • NPI 1679582944
  Care Compare affiliation
• Ihc Health Services Inc

  dba Intermountain Health Logan Regional Hospital

  • General Acute Care Hospital
  • Logan, UT
  • NPI 1831108497
  Care Compare affiliation

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

{
    "created_epoch": "1720137600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1724371200000",
    "number": "1639915911",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 912042",
            "city": "ST GEORGE",
            "state": "UT",
            "postal_code": "847912042",
            "telephone_number": "435-215-0230",
            "fax_number": "435-986-7092"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "630 E 1400 N STE 135",
            "city": "LOGAN",
            "state": "UT",
            "postal_code": "843412549",
            "telephone_number": "435-787-8146",
            "fax_number": "435-787-8149"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "JACOB",
        "credential": "A.P.R.N",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2024-07-05",
        "last_updated": "2024-08-23",
        "certification_date": "2024-08-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LG0600X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Gerontology",
            "state": "UT",
            "license": "7205712-4405",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "UT",
            "license": "7205712-4405",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Wal-Mart Stores, Inc. (Walmart Vision Cneter 30-4272)
• Walgreen Co (Walgreens #10552)
• Ada R Walker
• Corey Wyn Walker, M.D.
• Tracy Walker, PT
• Sarah Wallace, RDN
• Seth Browning Wallace, M.D.
• Walmart Inc. (WalMart Pharmacy 10-4272)
• Emma Louise Walton
• Isaac London Wanberg

• Family Nurse Practitioner in Logan, UT
• Providers in Logan, UT by specialty
• Family Nurse Practitioner in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 23, 2024; 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.