Jennifer Lea Wallace, PAC

Primary specialty

Medical Physician AssistantTaxonomy code 363AM0700X

License

PA9105134 Issued in FL

Practice address

625 6TH Ave S
Suite 385
Saint Petersburg, FL 33701-4662

Phone

(727) 553-7100

Fax

(727) 553-7198

NPI assigned

Jan 4, 2006

Sex

Female

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

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

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

{
    "created_epoch": "1136332800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1444262400000",
    "number": "1700864493",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "625 6TH AVE S",
            "address_2": "SUITE 385",
            "city": "SAINT PETERSBURG",
            "state": "FL",
            "postal_code": "337014662",
            "telephone_number": "727-553-7100",
            "fax_number": "727-553-7198"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "625 6TH AVE S",
            "address_2": "SUITE 385",
            "city": "SAINT PETERSBURG",
            "state": "FL",
            "postal_code": "337014662",
            "telephone_number": "727-553-7100",
            "fax_number": "727-553-7198"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "JENNIFER",
        "middle_name": "LEA",
        "credential": "PAC",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-01-04",
        "last_updated": "2015-10-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "FL",
            "license": "PA9105134",
            "primary": true
        },
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": "FL",
            "license": "PA9105134",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Wall Dermatology, LLC
• Kimberly Wall, CRT
• Weston Wall, MD
• Anna Joan Wallace, COTA
• Jennifer L Wallace, P.T.
• Jennifer M Wallace, PA-C
• Kristie Jackson Wallace, PHARMD
• Kristin Elise Wallace, LMHC
• Ora Wallace
• Robert Jennings Wallace, MD

• Medical Physician Assistant in Saint Petersburg, FL
• Providers in Saint Petersburg, FL by specialty
• Medical Physician Assistant in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 8, 2015; 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.