Jessica Lynn Wallace
Individual provider Active NPI Community/Behavioral Health Agency · Muse, OK
NPI 1659637478 · NPPES record last updated Apr 5, 2012
Key facts
- NPI
- 1659637478
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Community/Behavioral Health Agency 251S00000X
- Practice address
- 26652 Muse Road
Muse, OK 74949 - Phone
- (918) 567-1719
- NPI assigned
- Apr 5, 2012
- Sex
- Female
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community/Behavioral Health Agency | 251S00000X | Yes |
Addresses
Primary practice location
26652 Muse Road
Muse, OK 74949
Mailing address
Box 26652 St. Hwy. 63
Hodgen, OK 74939
Phone (918) 567-1719
Other providers in Muse, OK
All providers in Muse, OK · Community/Behavioral Health Agency in Oklahoma
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 5, 2012. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.