Provider Demographics
NPI:1427713288
Name:WALLACE, JESSICA LYNN (LPN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:HALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:65 CAMBRIAN WAY APT 110
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-2970
Mailing Address - Country:US
Mailing Address - Phone:802-503-8051
Mailing Address - Fax:
Practice Address - Street 1:65 CAMBRIAN WAY APT 110
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-2970
Practice Address - Country:US
Practice Address - Phone:802-503-8051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT025.0112709164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse