Provider Demographics
NPI:1447051107
Name:WALLACE, JESSICA EVE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:EVE
Last Name:WALLACE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 CHRISTY CRK
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-9660
Mailing Address - Country:US
Mailing Address - Phone:877-498-0319
Mailing Address - Fax:
Practice Address - Street 1:358 CHRISTY CRK
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-9660
Practice Address - Country:US
Practice Address - Phone:877-498-0319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician