Provider Demographics
NPI:1285911032
Name:WALLACE, JEANNE M (PHD)
Entity type:Individual
Prefix:
First Name:JEANNE
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1697 EAST 3450 NORTH
Mailing Address - Street 2:
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341
Mailing Address - Country:US
Mailing Address - Phone:435-563-0053
Mailing Address - Fax:435-538-8058
Practice Address - Street 1:1697 E 3450 N
Practice Address - Street 2:
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-8310
Practice Address - Country:US
Practice Address - Phone:435-563-0053
Practice Address - Fax:435-538-8058
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist