Jennifer Wallace, M.D.

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

31229 Issued in AZ

Practice address

2550 E Guadalupe Rd
#115
Gilbert, AZ 85234-5114

Phone

(480) 632-1544

Fax

(480) 632-1533

NPI assigned

Jan 24, 2006

Sex

Female

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 6

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

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

• Phoenix Children'S Hospital

  • Pediatrics Physician
  • Phoenix, AZ
  • NPI 1922112044
  NPD (past)

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

{
    "created_epoch": "1138060800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1912977885",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6301 S MCCLINTOCK DR",
            "address_2": "#101",
            "city": "TEMPE",
            "state": "AZ",
            "postal_code": "852833392",
            "telephone_number": "480-214-2300",
            "fax_number": "480-214-2301"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2550 E GUADALUPE RD",
            "address_2": "#115",
            "city": "GILBERT",
            "state": "AZ",
            "postal_code": "852345114",
            "telephone_number": "480-632-1544",
            "fax_number": "480-632-1533"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "JENNIFER",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-01-24",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "AZ",
            "license": "31229",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MAYO INSURANCE",
            "identifier": "031229",
            "state": "AZ"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DEPT. OF ECONOMIC SECURIT",
            "identifier": "8311240",
            "state": "AZ"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "831124",
            "state": "AZ"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "AZ0734620",
            "state": "AZ"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HEALTHNET",
            "identifier": "1Z9881",
            "state": "AZ"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BANNER HEALTH PLAN",
            "identifier": "00024623",
            "state": "AZ"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Michael Walker, PHARMD
• Stacey Lee Walker, R.D.H.
• Suzanne Renee Walker, LCSW, LISW
• Mariah Walkington, RN
• Kevin Ray Wall, DC
• Keith Wallace
• Waller Systems, LLC
• Morgan Wallis, LAC
• Walmart Inc.
• Walmart Inc.

• Pediatrics Physician in Gilbert, AZ
• Providers in Gilbert, AZ by specialty
• Pediatrics Physician in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; 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.