Provider Demographics
NPI:1083907299
Name:WALLACE, JESSICA (MA, NCC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MA, NCC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:DOUGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:5004 JENKINS RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-2227
Mailing Address - Country:US
Mailing Address - Phone:865-567-2899
Mailing Address - Fax:
Practice Address - Street 1:10414 JACKSON OAKS WAY STE 103
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-0704
Practice Address - Country:US
Practice Address - Phone:865-567-2899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-20
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 104100000X
TN6639101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker