Provider Demographics
NPI:1871974527
Name:WALLACE, JACOB (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WALLACE
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 W IRON AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401-2600
Mailing Address - Country:US
Mailing Address - Phone:785-827-9526
Mailing Address - Fax:785-827-2854
Practice Address - Street 1:119 W IRON AVE FL 5
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401-2600
Practice Address - Country:US
Practice Address - Phone:785-827-9526
Practice Address - Fax:785-827-2854
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-17
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS94-08609207R00000X
KS04-446132085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine