Provider Demographics
NPI:1306642996
Name:WALLACE, JENNIFER K (DNP, APRN, FNP-BC)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:K
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DNP, APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 PEYTON PL
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-5067
Mailing Address - Country:US
Mailing Address - Phone:630-388-8262
Mailing Address - Fax:
Practice Address - Street 1:2496 DEKALB AVE
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3293
Practice Address - Country:US
Practice Address - Phone:815-787-3678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.031651363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily