Provider Demographics
NPI:1215981170
Name:WALLACE, JESSICA ELIZABETH (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:ELIZABETH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 N SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-2910
Practice Address - Country:US
Practice Address - Phone:310-802-0200
Practice Address - Fax:310-794-9035
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA547962163W00000X
CA10241363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN547962OtherMEDICAL
CAWNP10241AMedicare ID - Type Unspecified
CARN547962OtherMEDICAL