Jennifer Lyn Wallace, MD

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

MD24427 Issued in OR

Practice address

1235 SE Division St
Suite 208
Portland, OR 97202-1099

Phone

(888) 480-1115

NPI assigned

Feb 20, 2006

Sex

Female

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective May 19, 2017 through May 19, 2027

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

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

{
    "created_epoch": "1140393600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1205798400000",
    "number": "1730154154",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1235 SE DIVISION ST",
            "address_2": "SUITE 208",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972021099",
            "telephone_number": "888-480-1115"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1235 SE DIVISION ST",
            "address_2": "SUITE 208",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972021099",
            "telephone_number": "888-480-1115"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "JENNIFER",
        "middle_name": "LYN",
        "credential": "MD",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2006-02-20",
        "last_updated": "2008-03-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "OR",
            "license": "MD24427",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "232919",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Elizabeth Frances Wallace, MA, LPC
• Elizabeth Spagat Wallace, ND,LAC
• Erin Wallace, OTD, OTR/L
• Harrison James Wallace
• Jacqueline Vasquez Wallace
• Jessica M Wallace, CRNA
• Jessica Zoee Savage Wallace
• Jodi Wallace
• Joy Michelle Wallace, QMHA
• Juliana Elizabeth Wallace, MSW ACSW, CADC III

• Family Medicine Physician in Portland, OR
• Providers in Portland, OR by specialty
• Family Medicine Physician in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 18, 2008; 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; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.