Provider Demographics
NPI:1063291789
Name:WALLACE, JORDAN JEHREE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JORDAN
Middle Name:JEHREE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA-C
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Other - First Name:
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Mailing Address - Street 1:4301 W MARKHAM ST # 783
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-7101
Mailing Address - Country:US
Mailing Address - Phone:501-686-8000
Mailing Address - Fax:501-526-5148
Practice Address - Street 1:4301 W MARKHAM ST # 721
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:501-526-6062
Practice Address - Fax:501-686-5780
Is Sole Proprietor?:No
Enumeration Date:2023-09-22
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARPA-1208363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical