Provider Demographics
NPI:1609751080
Name:WALLACE, JACKIE (CRPA)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:CRPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 MT.HOPE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620
Mailing Address - Country:US
Mailing Address - Phone:585-706-7983
Mailing Address - Fax:
Practice Address - Street 1:2069 HUDSON AVE.
Practice Address - Street 2:D
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14617
Practice Address - Country:US
Practice Address - Phone:585-694-1307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-06
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty