Provider Demographics
NPI:1194892620
Name:WALLACE, JASMINE ALICIA (BS)
Entity type:Individual
Prefix:MS
First Name:JASMINE
Middle Name:ALICIA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:610 SEWALL AVE APT 5R
Mailing Address - Street 2:
Mailing Address - City:ASBURY PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-6540
Mailing Address - Country:US
Mailing Address - Phone:732-747-9660
Mailing Address - Fax:732-224-1396
Practice Address - Street 1:145 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1717
Practice Address - Country:US
Practice Address - Phone:732-747-9660
Practice Address - Fax:732-224-1396
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor