Provider Demographics
NPI:1285517409
Name:SPINKS, WALLACE JAY
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:JAY
Last Name:SPINKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:SHASTA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:96019-9767
Mailing Address - Country:US
Mailing Address - Phone:530-225-5556
Mailing Address - Fax:
Practice Address - Street 1:1405 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:SHASTA LAKE
Practice Address - State:CA
Practice Address - Zip Code:96019-9767
Practice Address - Country:US
Practice Address - Phone:530-225-5556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-26
Last Update Date:2025-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health