Provider Demographics
NPI:1285384776
Name:WALLACE, JACY SHEA
Entity type:Individual
Prefix:
First Name:JACY
Middle Name:SHEA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10251 N 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-1305
Mailing Address - Country:US
Mailing Address - Phone:602-926-7200
Mailing Address - Fax:
Practice Address - Street 1:3910 S ALMA SCHOOL RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85248-4498
Practice Address - Country:US
Practice Address - Phone:602-926-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-27
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBEH-001284103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst